Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage: A Closed Claims Analysis

CT based 3D radiomic and clinical airway examination model for evaluating mask ventilation in oral and maxillofacial surgery patients

The objective of this study is to develop a model that incorporates clinical measurements with 3D radiomic signatures extracted from CT images of oral and maxillofacial surgery patients to evaluate mask ventilation. A prospective cohort trial was conducted to enroll patients scheduled for oral and maxillofacial surgery. After obtaining informed consent, clinical measurements and head and neck CT images were collected. The anesthesiologist who managed the airway graded the mask ventilation. Difficult mask ventilation was defined as mask ventilation that required assistance or the use of an oral airway or other adjuvant by the anesthesiologist. For radiomics analysis, 3D airway segmentation was extracted and calculated 3D radiomic signatures and corresponding radiological features. Subsequently, features in the clinical measurements model and radiomic signatures model were determined using the least absolute shrinkage and selection operator (LASSO) classifier. A mixed model was developed that incorporated both radiomic signature features and clinical measurement features. A total of 716 patients were enrolled in the study. The mixed model combined the five 3D radiomic signatures and six clinical measurements, and was found to have the highest predictive accuracy. In the validation group, the mixed group had an area under the curve (AUC) of 0.851, which was higher than the AUC of 0.812 in the clinical measurements model and 0.827 in the radiomic signatures model. This study developed a mixed model that combines 3D radiomic signatures and clinical measurements. Its application in clinical practice can assist in identifying patients at risk of experiencing difficult mask ventilation during oral and maxillofacial surgeries.

Medication errors and mitigation strategies in obstetric anesthesia

PURPOSE OF REVIEW

Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

RECENT FINDINGS

Cases of medication errors involving unintended intrathecal administration of tranexamic acid highlight the need to improve medication safety in peripartum patients and obstetric anesthesia.

SUMMARY

In obstetric anesthesia, medication errors can include wrong medication, dose, route, time, patient, or infusion setting. These errors are often underreported, have the potential to be catastrophic, and most can be prevented. Implementation of various types of best practice cost effective mitigation strategies include recommendations to improve drug labeling, optimize storage, determine correct medication prior to administration, use non-Luer epidural and intravenous connection ports, follow patient monitoring guidelines, use smart pumps and protocols for all infusions, disseminate medication safety educational material, and optimize staffing models. Vigilance in patient care and implementation of improved patient safety measures are urgently needed to decrease harm to mothers and newborns worldwide.

Avatar-based versus conventional patient monitoring with distant vision: a computer-based simulation study

Patient monitoring in the perioperative setting can be challenging, especially when monitoring multiple patients simultaneously or managing dynamic situations that require movement around the operating room. We aimed to evaluate whether avatar-based patient monitoring, which presents vital signs in the form of changing colors, shapes and motion, improves remote vital sign recognition compared to conventional monitoring. We conducted a prospective, single-center, computer-based simulation study to evaluate how anesthesia providers recognize vital signs when using the Philips Visual Patient Avatar at different viewing distances (8 and 16 m) compared to conventional monitoring. The primary outcome was the total number of correctly identified vital signs which were compared for the two distances and the two devices using mixed Poisson regression. We analyzed data from 28 anesthesia providers who participated in 112 simulations. The correct recognition rate using the Visual Patient Avatar compared to conventional monitoring at 8 m was increased by 74% (rate ratio 1.74, 95% CI, 1.42 to 2.14, p < 0.001) and by 51% at 16-meter viewing distance (rate ratio 1.51, 95% CI, 1.23 to 1.87, p < 0.001). We observed scenario-specific superior performance for six vital signs at 8 m. The results provide empirical evidence that avatar-based monitoring can significantly improve the perception of vital signs when using distant vision.

Survey-based qualitative exploration of user perspectives on the philips visual patient avatar in clinical situation management

Philips Visual Patient Avatar is an innovative approach to patient monitoring. Computer-based simulation studies have shown that it can improve diagnostic accuracy and confidence while reducing perceived workload. Following its integration into clinical practice, we conducted a single-centre qualitative study at the University Hospital Zurich to explore the views of anaesthesia, post-anaesthesia and intensive care providers on their experience with the technology. We used an online survey to assess its contributions in different clinical situations. We analysed the data thematically to identify key themes. Of the 510 healthcare providers contacted, 131 (25.7%) completed the survey and 154 comments were collected. Key themes included the detection of specific vital sign changes, focusing on temperature and oxygen saturation (41.9%, 34/81 comments in the operating room; 38.6%, 17/44 comments in the intensive care unit; 10.3%, 3/29 comments in the post-anaesthesia care unit). Additionally, the technology was perceived to support daily routines and situational awareness (28.4%, 23/81 comments in the OR; 9.1%, 4/44 comments in the ICU; 10.3%, 3/29 comments in the PACU). The study provides early, but strong evidence that the Philips Visual Patient Avatar assists healthcare providers in specific clinical situations in the perioperative and critical care settings.

Identifying intraoperative events in a simulated laparotomy video: a multinational study of inattentional blindness among anesthesiologists

PURPOSE

Medical errors may be occasionally explained by inattentional blindness (IB), i.e., failing to notice an event/object that is in plain sight. We aimed to determine whether age/experience, restfulness/fatigue, and previous exposure to simulation education may affect IB in the anesthetic/surgical setting.

METHODS

In this multicentre/multinational study, a convenience sample of 280 anesthesiologists watched an attention-demanding video of a simulated trauma patient undergoing laparotomy and (independently/anonymously) recorded the abnormalities they noticed. The video contained four expected/common abnormalities (hypotension, tachycardia, hypoxia, hypothermia) and two prominently displayed unexpected/rare events (patient's head movement, leaky central venous line). We analyzed the participants' ability to notice the expected/unexpected events (primary outcome) and the proportion of expected/unexpected events according to age group and prior exposure to simulation education (secondary outcomes).

RESULTS

Anesthesiologists across all ages noticed fewer unexpected/rare events than expected/common ones. Overall, younger anesthesiologists missed fewer common events than older participants did (P = 0.02). There was no consistent association between age and perception of unexpected/rare events (P = 0.28), although the youngest cohort (< 30 yr) outperformed the other age groups. Prior simulation education did not affect the proportion of misses for the unexpected/rare events but was associated with fewer misses for the expected/common events. Self-perceived restfulness did not impact perception of events.

CONCLUSION

Anesthesiologists noticed fewer unexpected/rare clinical events than expected/common ones in an attention-demanding video of a simulated trauma patient, in keeping with IB. Prior simulation training was associated with an improved ability to notice anticipated/expected events, but did not reduce IB. Our findings may have implications for understanding medical mishaps, and efforts to improve situational awareness, especially in acute perioperative and critical care settings.

Use of artificial intelligence in critical care: opportunities and obstacles

BACKGROUND

Perhaps nowhere else in the healthcare system than in the intensive care unit environment are the challenges to create useful models with direct time-critical clinical applications more relevant and the obstacles to achieving those goals more massive. Machine learning-based artificial intelligence (AI) techniques to define states and predict future events are commonplace activities of modern life. However, their penetration into acute care medicine has been slow, stuttering and uneven. Major obstacles to widespread effective application of AI approaches to the real-time care of the critically ill patient exist and need to be addressed.

MAIN BODY

Clinical decision support systems (CDSSs) in acute and critical care environments support clinicians, not replace them at the bedside. As will be discussed in this review, the reasons are many and include the immaturity of AI-based systems to have situational awareness, the fundamental bias in many large databases that do not reflect the target population of patient being treated making fairness an important issue to address and technical barriers to the timely access to valid data and its display in a fashion useful for clinical workflow. The inherent "black-box" nature of many predictive algorithms and CDSS makes trustworthiness and acceptance by the medical community difficult. Logistically, collating and curating in real-time multidimensional data streams of various sources needed to inform the algorithms and ultimately display relevant clinical decisions support format that adapt to individual patient responses and signatures represent the efferent limb of these systems and is often ignored during initial validation efforts. Similarly, legal and commercial barriers to the access to many existing clinical databases limit studies to address fairness and generalizability of predictive models and management tools.

CONCLUSIONS

AI-based CDSS are evolving and are here to stay. It is our obligation to be good shepherds of their use and further development.

Deep learning-based facial analysis for predicting difficult videolaryngoscopy: a feasibility study

While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet-18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack-Lehane grade of 1 or 2 was classified as 'non-difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non-difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733-0.825) with a sensitivity (95%CI) of 0.757 (0.650-0.845) and specificity (95%CI) of 0.721 (0.626-0.794) in the test set. Compared with bedside examination and multivariate scores (El-Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence-based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods.

Improving Situation Awareness to Advance Patient Outcomes: A Systematic Literature Review

Improving nurses' situation awareness skills would likely improve patient status recognition and prevent adverse events. Technologies such as electronic health record dashboards can be a promising approach to support nurses' situation awareness. However, the effect of these dashboards on this skill is unknown. This systematic literature review explores the evidence around interventions to improve nurses' situation awareness at the point of care. Current research on this subject is limited. Studies that examined the use of electronic health record dashboards as an intervention had weak evidence to support their effectiveness. Other interventions, including communication interventions and structured nursing assessments, may also improve situation awareness, but more research is needed to confirm this. It is important to carefully consider the design and content of situation awareness interventions, as well as the specific outcomes being measured, when designing situation awareness interventions. Overall, there is a need for higher-quality research in this area to determine the most effective interventions for improving nurse situation awareness. Future studies should focus on developing dashboards that follow a theoretical situation awareness model information and represent all situation awareness levels.

Qualitative Exploration of Anesthesia Providers' Perceptions Regarding Philips Visual Patient Avatar in Clinical Practice

The Philips Visual Patient Avatar, a user-centered visualization technology, offers an alternative approach to patient monitoring. Computer-based simulation studies indicate that it increases diagnostic accuracy and confidence, while reducing perceived workload. About three months after the technology's integration into clinical practice, we conducted an assessment among anesthesia providers to determine their views on its strengths, limitations, and overall perceptions. This single-center qualitative study at the University Hospital of Zurich examined anesthesia providers' perceptions of the Philips Visual Patient Avatar after its implementation. The study included an online survey to identify medical personnel's opinions on the technology's strengths and areas for improvement, which were analyzed using thematic analysis. A total of 63 of the 377 invited anesthesia providers (16.7%) responded to the survey. Overall, 163 comments were collected. The most prevalent positive themes were good presentation of specific parameters (16/163; 9.8%) and quick overview/rapid identification of problems (15/163; 9.2%). The most common perceived area for improvement was the ability to adjust the visualization thresholds of Visual Patient Avatar, which represent the physiological upper and lower vital-sign limits (33/163; 20.3%). The study showed that users consider Philips Visual Patient Avatar a valuable asset in anesthesia, allowing for easier identification of underlying problems. However, the study also revealed a user desire for the ability to freely adjust the thresholds of the Visual Patient Avatar by the handling caregivers, which were fixed to the departmental standard during the study.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Exploring eye-tracking data as an indicator of situational awareness in nursing students during a cardiorespiratory arrest simulation

AIM

To examine the components of visual attention that maintain situational awareness during simulation training in undergraduate nursing students with different instruction levels.

BACKGROUND

Eye-tracking can provide deep insight into the nurses' attention during simulated practice. Knowing which gaze patterns promote situational awareness can significantly improve nurse instruction.

DESIGN

A comparative observational study investigated the role of visual attention on the performance quality, psychophysiological parameters (vital signs, anxiety and stress) and socioemotional competencies (cognitive workload, motivation and self-efficacy) of nursing students with various experience levels.

METHODS

Thirty nursing students divided into two groups according to their academic level: first cycle (n=14) and second-cycle (n=16) faced a clinical simulation scenario to resolve a cardiorespiratory arrest event. Eye tracking-based analysis required the selection of six areas of interest. The monitorization of vital signs included measuring blood pressure, heart rate, respiratory rate and oxygen saturation before and after the simulation practice. Participants completed the socioemotional questionnaire (NASA-TLX). They answered the state subscale of the State-Trait Anxiety Inventory (STAI), the Visual Analogue Scale (VAS) of stress, the Situational Motivation Scale (SIMS) and the Baessler and Schwarzer General Self-Efficacy Scale.

RESULTS

The first-cycle group displayed higher vital sign scores than the second cycle, apart from the post-simulation respiratory rate. All physiological parameters increased in mean value after the clinical simulation, except oxygen saturation. Anxiety was the only parameter in the socioemotional domain to present a statistically significant difference between the groups. First-year nursing students showed greater anxiety, stress, mental workload, identified regulation and intrinsic motivation, while second-year students showed higher levels of amotivation, external regulation and perceived self-efficacy. Eye-tracking data (revisits, gaze and duration of fixations) exhibited statistically significant differences depending on the area of interest in both groups (p =. 05). The performance outcomes showed a negative and moderate association with gaze the total number of gazes in the second-cycle group (rho = -0.640, p = 0.010).

CONCLUSION

Eye-tracking-based analysis can help to predict performance quality while maintaining situational awareness during nursing instruction.

Pediatric Anesthesia Providers' Perspective on the Real-Life Implementation of the Philips Visual Patient Avatar: A Qualitative Study

The Philips Visual Patient Avatar represents an alternative method of patient monitoring that, according to computer-based simulation studies, enhances diagnostic accuracy and confidence and reduces workload. After its clinical integration, we assessed pediatric anesthesia providers' perspectives on this technology. This is a single-center qualitative study, conducted at the University Hospital Zurich using in-depth individual interviews. We aimed to identify the advantages and limitations of the Visual Patient Avatar in pediatric anesthesia and to assess children's and parents' reactions from caregivers' perspectives. Thematic analysis was used to identify the dominant themes. Fourteen members of the institution's pediatric anesthesia team were interviewed. The most prevalent themes were children's positive reactions towards the Visual Patient Avatar (92.9%) and enhanced speed in problem identification (71.4%). Additionally, 50% of participants reported finding the Visual Patient Avatar useful for diverting children's attention during anesthesia induction, and 50% suggested that its vital sign thresholds should be adaptable for different age groups. The study revealed that the Visual Patient Avatar was recognized as a tool in pediatric anesthesia, enabling prompt identification of underlying issues and receiving positive feedback from both children and parents. The most commonly voiced wish for improvement in the study was the ability to customize the Visual Patient Avatar's thresholds for different age groups.

Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: A simulation-based observational study

STUDY OBJECTIVE

In a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation.

DESIGN

Prospective, simulation-based, observational study.

SETTING

An anesthesia crisis resource management course at a freestanding simulation center.

SUBJECTS

Sixty attending anesthesiologists from a variety of practice settings.

INTERVENTIONS

In each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset.

MEASUREMENTS

Simulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared.

RESULTS

Nineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s).

CONCLUSIONS

Despite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.

Development and validation of a regression model with nomogram for difficult video laryngoscopy in Chinese population: a prospective, single-center, and nested case-control study

Background

Airway management failure is associated with increased perioperative morbidity and mortality. Airway-related complications can be significantly reduced if difficult laryngoscopy is predicted with high accuracy. Currently, there are no large-sample studies on difficult airway assessments in Chinese populations. An airway assessment model based on the Chinese population is urgently needed to guide airway rescue strategy.

Methods

This prospective nested case-control study took place in a tertiary hospital in Shanghai, China. Information on 10,549 patients was collected, and 8,375 patients were enrolled, including 7,676 patients who underwent successful laryngoscopy and 699 patients who underwent difficult laryngoscopy. The baseline characteristics, medical history, and bedside examinations were included as predictor variables. Laryngoscopy was defined as 'successful laryngoscopy' based on a Cormack-Lehane Grades of 1-2 and as 'difficult laryngoscopy' based on a Cormack-Lehane Grades of 3-4. A model was developed by incorporating risk factors and was presented in the form of a nomogram by univariate logistic regression, least absolute shrinkage and selection operator, and stepwise logistic regression. The main outcome measures were area under the curve (AUC), sensitivity, and specificity of the predictive model.

Result

The AUC value of the prediction model was 0.807 (95% confidence interval [CI]: 0.787-0.828), with a sensitivity of 0.730 (95% CI, 0.690-0.769) and a specificity of 0.730 (95% CI, 0.718-0.742) in the training set. The AUC value of the prediction model was 0.829 (95% CI, 0.800-0.857), with a sensitivity of 0.784 (95% CI, 0.73-0.838) and a specificity of 0.722 (95% CI, 0.704-0.740) in the validation set.

Conclusion

Our model had accurate predictive performance, good clinical utility, and good robustness for difficult laryngoscopy in the Chinese population.

Using the Endsley Model to Evaluate Simulation-Based Situation Awareness Training for Medical and Nursing Students in India: A Qualitative Analysis

INTRODUCTION

Situation awareness (SA) training is a vital part of healthcare training, and opportunities to provide SA training to healthcare workers are limited in low- and middle-income countries. We aimed to analyze undergraduate medical and nursing students' perception of their understanding of SA through an interprofessional obstetric neonatal emergency simulation workshop (ONE-Sim) and subsequently evaluate their perceived changes in SA understanding using the Endsley model ( Hum Factors 1995;37(1):32-64).

METHODS

Feedback on SA before and after the workshop was collected through questionnaire-based surveys. Thematic analysis was performed, with themes emerging from an inductive analysis followed by a deductive analysis using the Endsley model.

RESULTS

The themes emerging from the inductive analysis included environmental awareness, evolving knowledge, skill development, and applicability to practice. These aligned with the 3 levels of SA in the Endsley model in the deductive analysis suggesting that participants transformed their perception, comprehension, and projection of SA after the workshop.

CONCLUSION

Simulation-based education enhanced SA perception in obstetric and neonatal emergencies for medical and nursing students in a low- and middle-income country, and the Endsley model is a feasible framework to measure learner perceived changes in SA understanding through simulation-based education.

Guidelines on human factors in critical situations 2023

OBJECTIVE

To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.

DESIGN

A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

Human-centered visualization technologies for patient monitoring are the future: a narrative review

Medical technology innovation has improved patient monitoring in perioperative and intensive care medicine and continuous improvement in the technology is now a central focus in this field. Because data density increases with the number of parameters captured by patient-monitoring devices, its interpretation has become more challenging. Therefore, it is necessary to support clinicians in managing information overload while improving their awareness and understanding about the patient's health status. Patient monitoring has almost exclusively operated on the single-sensor-single-indicator principle-a technology-centered way of presenting data in which specific parameters are measured and displayed individually as separate numbers and waves. An alternative is user-centered medical visualization technology, which integrates multiple pieces of information (e.g., vital signs), derived from multiple sensors into a single indicator-an avatar-based visualization-that is a meaningful representation of the real-world situation. Data are presented as changing shapes, colors, and animation frequencies, which can be perceived, integrated, and interpreted much more efficiently than other formats (e.g., numbers). The beneficial effects of these technologies have been confirmed in computer-based simulation studies; visualization technologies improved clinicians' situation awareness by helping them effectively perceive and verbalize the underlying medical issue, while improving diagnostic confidence and reducing workload. This review presents an overview of the scientific results and the evidence for the validity of these technologies.

Visual Blood, a 3D Animated Computer Model to Optimize the Interpretation of Blood Gas Analysis

Acid–base homeostasis is crucial for all physiological processes in the body and is evaluated using arterial blood gas (ABG) analysis. Screens or printouts of ABG results require the interpretation of many textual elements and numbers, which may delay intuitive comprehension. To optimise the presentation of the results for the specific strengths of human perception, we developed Visual Blood, an animated virtual model of ABG results. In this study, we compared its performance with a conventional result printout. Seventy physicians from three European university hospitals participated in a computer-based simulation study. Initially, after an educational video, we tested the participants’ ability to assign individual Visual Blood visualisations to their corresponding ABG parameters. As the primary outcome, we tested caregivers’ ability to correctly diagnose simulated clinical ABG scenarios with Visual Blood or conventional ABG printouts. For user feedback, participants rated their agreement with statements at the end of the study. Physicians correctly assigned 90% of the individual Visual Blood visualisations. Regarding the primary outcome, the participants made the correct diagnosis 86% of the time when using Visual Blood, compared to 68% when using the conventional ABG printout. A mixed logistic regression model showed an odds ratio for correct diagnosis of 3.4 (95%CI 2.00–5.79, p < 0.001) and an odds ratio for perceived diagnostic confidence of 1.88 (95%CI 1.67–2.11, p < 0.001) in favour of Visual Blood. A linear mixed model showed a coefficient for perceived workload of −3.2 (95%CI −3.77 to −2.64) in favour of Visual Blood. Fifty-one of seventy (73%) participants agreed or strongly agreed that Visual Blood was easy to use, and fifty-five of seventy (79%) agreed that it was fun to use. In conclusion, Visual Blood improved physicians’ ability to diagnose ABG results. It also increased perceived diagnostic confidence and reduced perceived workload. This study adds to the growing body of research showing that decision-support tools developed around human cognitive abilities can streamline caregivers’ decision-making and may improve patient care.

The effects of TeamSTEPPS implementation by nurses on situation monitoring in hospital

Introduction: Patient safety is a healthcare system, which minimizes the occurrence and impact of side effects. It also helps to facilitate full recovery in patients, and efforts to improve their safety require teamwork, such as situation monitoring by nurses. Therefore, this study aims to determine the effects of TeamSTEPPS implementation by nurses on situation monitoring in hospitals. Design and Methods: A quasi-experimental pre-post test design was used with a total of 56 nurses, which were selected using the purposive sampling technique. They were then shared equally into 2 groups, namely control and intervention groups. Results: The unpaired t-test result shows that the value of |t count| was lower than the t table (0.210 < 2.005), while the p-value was greater than α (0.835 > 0.050). This result indicates that implementing TeamSTEPPS by nurses have an insignificant effect on situation monitoring in the hospital. Conclusions: In conclusion, hospitals are advised to implement TeamSTEPPS regularly to improve teamwork, specifically in situation monitoring by nurses.

Measurement of Information Transfer During Simulated Sequential Complete Shift-to-Shift Intraoperative Handoffs

Objective

To determine information transfer during simulated shift-to-shift intraoperative anesthesia handoffs and the benefits of using a handoff tool.

Patients and Methods

Anesthesiology residents and faculty participating in simulation-based education in a simulation center on April 6 and 20, 2017, and April 11 and 25, 2019. We used a fixed clinical scenario to compare information transfer in multiple sequential simulated handoff chains conducted from memory or guided by an electronic medical record generated tool. For each handoff, 25 informational elements were assessed on a discrete 0-2 scale generating a possible information retention score of 50. Time to handoff completion and number of clarifications requested by the receiver were also determined.

Results

We assessed 32 handoff chains with up to 4 handoffs per chain. When both groups were combined, the mean information retention score was 31 of 50 (P<.001) for the first clinician and declined by an average of 4 points per handoff (P<.001). The handoff tool improved information retention by almost 7 points (P=.002), but did not affect the rate of information degradation (P=.38). Handoff time remained constant for the intervention group (P=.67), but declined by 2 minutes/handoff (P<.001) in the control group, which required 7 more clarifications/handoff (P=.003). In the control group, 7 of 16 (44%) handoff chains contained one or more information retention scores below the lowest score of the entire intervention group (P=.007).

Conclusion

Clinical handoffs are accompanied by degradation of information that is only partially reduced by use of a handoff tool, which appears to prevent extremes of information degradation.

Videolaryngoscopy as a first-intention technique for tracheal intubation in unselected surgical patients: a before and after observational study

BACKGROUND

Using a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation of unselected patients in the operating room has not often been studied. We hypothesised that using a Macintosh-style videolaryngoscope as a first-intention device is associated with an increased proportion of easy tracheal intubation.

METHODS

In a quality improvement project for airway management aimed at implementing a Macintosh-style videolaryngoscope as a first-intention device, we included all consecutive tracheal intubations in adults from March, 2017 to September, 2020 in two French teaching hospitals. We divided the cohort into three temporal cohorts: the pre-intervention, implementation, and post-intervention periods. The primary outcome was the proportion of easy airway management. The secondary outcomes were the rescue technique, Cormack-Lehane III or IV view, and operator-reported difficulty of intubation. Data from one hospital compliant with the quality improvement project were compared with data from a non-compliant hospital.

RESULTS

A total of 26 692 tracheal intubations were performed. Among 11 938 intubations included in the compliant hospital, 5487 were included in the pre-intervention, 1845 in the implementation, and 4606 in the post-intervention periods. In comparison to the pre-intervention period, the proportions of easy tracheal intubation increased from 94.3% (5177 of 5487) to 98.7% (4547 of 4606)) in the post-intervention period (+4.4% [95% confidence interval 3.7-5.1%], P<0.001). In comparison to the pre-intervention period, all secondary outcome proportions were significantly lower in the post-intervention period. No significant changes were noted in the non-compliant hospital between the pre- and post-intervention periods.

CONCLUSIONS

Using a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation in the operating room was associated with a significant increase in the proportion of easy tracheal intubation, compared with use of the standard Macintosh laryngoscope.

Human Factors and Airway Management in COVID-19 Patients: The Perfect Storm?

The SARS-CoV-2 pandemic heavily impacted healthcare workers, increasing their physical and psychological workload. Specifically, COVID-19 patients' airway management is definitely a challenging task regarding both severe and acute respiratory failure and the risk of contagion while performing aerosol-generating procedures. The category of anesthesiologists and intensivists, the main actors of airway management, showed a poor psychological well-being and a high stress and burnout risk. Identifying and better defining the specific main SARS-CoV-2-related stressors can help them deal with and effectively plan a strategy to manage these patients in a more confident and safer way. In this review, we therefore try to analyze the relevance of human factors and non-technical skills when approaching COVID-19 patients. Lessons from the past, such as National Audit Project 4 recommendations, have taught us that safe airway management should be based on preoperative assessment, the planning of an adequate strategy, the optimization of setting and resources and the rigorous evaluation of the scenario. Despite, or thanks to, the critical issues and difficulties, the "take home lesson" that we can translate from SARS-CoV-2 to every airway management is that there can be no more room for improvisation and that creating teamwork must become a priority.

Anesthesia personnel’s visual attention regarding patient monitoring in simulated non-critical and critical situations, an eye-tracking study

Background

Cognitive ergonomics design of patient monitoring may reduce human factor errors in high-stress environments. Eye-tracking is a suitable tool to gain insight into the distribution of visual attention of healthcare professionals with patient monitors, which may facilitate their further development.

Methods

This prospective, exploratory, high-fidelity simulation study compared anesthesia personnel’s visual attention (fixation count and dwell-time) to 15 areas of interest on the patient monitor during non-critical and critical anesthesia situations. Furthermore, we examined the extent to which participants’ experience influenced visual attention and which vital signs displayed on the patient monitor received the most visual attention. We used mixed zero-inflated Poisson regression and mixed linear models to analyze the data.

Results

Analyzing 23 ten-minute scenarios, we found significantly more fixations to the areas of interest on the patient monitor during critical than non-critical situations (rate ratio of 1.45; 95% CI 1.33 to 1.59; p < 0.001). However, the dwell-time on the areas of interest did not significantly differ between the non-critical and critical situations (coefficient of − 1.667; 95% CI − 4.549 to 1.229; p = 0.27). The professional experience did not significantly influence the visual attention (fixation: rate ratio of 0.88; 95% CI 0.54 to 1.43; p = 0.61 and dwell-time: coefficient of 0.889; 95% CI − 1.465 to 3.229; p = 0.27).

Over all situations, anesthesia personnel paid the most attention to the vital signs blood pressure (fixation: mean [SD] of 108 [74.83]; dwell-time: mean [SD] of 27 [15.90] seconds), end-expiratory carbon dioxide (fixation: mean [SD] of 59 [47.39]; dwell-time: mean [SD] of 30 [21.51] seconds), and the electrocardiogram (fixation: mean [SD] of 58 [64.70]; dwell-time: mean [SD] of 15 [14.95] seconds).

Conclusions

Critical anesthesia situations increased anesthesia personnel’s visual interaction with the patient monitor. Furthermore, we found that their visual attention focused mainly on a few vital signs. To assist clinicians in critical situations, manufacturers should optimize monitors to convey necessary information as easily and quickly as possible and optimize the visibility of less frequently observed but equally critical vital signs, especially when they are in an abnormal range.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01705-6.

Tracheal intubation in the critically ill patient

Tracheal intubation is among the most commonly performed and high-risk procedures in critical care. Indeed, 45% of patients undergoing intubation experience at least one major peri-intubation adverse event, with cardiovascular instability being the most common event reported in 43%, followed by severe hypoxemia in 9% and cardiac arrest in 3% of cases. These peri-intubation adverse events may expose patients to a higher risk of 28-day mortality, and they are more frequently observed with an increasing number of attempts to secure the airway. The higher risk of peri-intubation complications in critically ill patients, compared with the anaesthesia setting, is the consequence of their deranged physiology (e.g. underlying respiratory failure, shock and/or acidosis) and, in this regard, airway management in critical care has been defined as "physiologically difficult". In recent years, several randomised studies have investigated the most effective preoxy-genation strategies, and evidence for the use of positive pressure ventilation in moderate-to-severe hypoxemic patients is established. On the other hand, evidence on interventions to mitigate haemodynamic collapse after intubation has been elusive. Airway management in COVID-19 patients is even more challenging because of the additional risk of infection for healthcare workers, which has influenced clinical choices in this patient group. The aim of this review is to provide an update of the evidence for intubation in critically ill patients with a focus on understanding peri-intubation risks and evaluating interventions to prevent or mitigate adverse events.

Improving Visual-Patient-Avatar Design Prior to Its Clinical Release: A Mixed Qualitative and Quantitative Study

Visual-Patient-avatar, an avatar-based visualisation of patient monitoring, is a newly developed technology aiming to promote situation awareness through user-centred design. Before the technology’s introduction into clinical practice, the initial design used to validate the concept had to undergo thorough examination and adjustments where necessary. This mixed qualitative and quantitative study, consisting of three different study parts, aimed to create a design with high user acceptance regarding perceived professionalism and potential for identification while maintaining its original functionality. The first qualitative part was based on structured interviews and explored anaesthesia personnel’s first impressions regarding the original design. Recurrent topics were identified using inductive coding, participants’ interpretations of the vital sign visualisations analysed and design modifications derived. The second study part consisted of a redesign process, in which the visualisations were adapted according to the results of the first part. In a third, quantitative study part, participants rated Likert scales about Visual-Patient-avatar’s appearance and interpreted displayed vital signs in a computer-based survey. The first, qualitative study part included 51 structured interviews. Twenty-eight of 51 (55%) participants mentioned the appearance of Visual-Patient-avatar. In 23 of 51 (45%) interviews, 26 statements about the general impression were identified with a balanced count of positive (14 of 26) and negative (12 of 26) comments. The analysis of vital sign visualisations showed deficits in several vital sign visualisations, especially central venous pressure. These findings were incorporated into part two, the redesign of Visual-Patient-avatar. In the subsequent quantitative analysis of study for part three, 20 of 30 (67%) new participants agreed that the avatar looks professional enough for medical use. Finally, the participants identified 73% (435 of 600 cases) of all vital sign visualisations intuitively correctly without prior instruction. This study succeeded in improving the original design with good user acceptance and a reasonable degree of intuitiveness of the new, revised design. Furthermore, the study identified aspects relevant for the release of Visual-Patient-avatar, such as the requirement for providing at least some training, despite the design’s intuitiveness. The results of this study will guide further research and improvement of the technology. The study provides a link between Visual-Patient-avatar as a scientific concept and as an actual product from a cognitive engineering point of view, and may serve as an example of methods to study the designs of technologies in similar contexts.

Anesthesia providers' visual attention in simulated anesthesia emergencies using conventional number-based and avatar-based patient monitoring: a prospective, eye-tracking study

BACKGROUND

Inadequate situational awareness accounts for two-thirds of preventable complications in anesthesia. An essential tool for situational awareness in the perioperative setting is the patient monitor. However, the conventional monitor has several weaknesses. Avatar-based patient monitoring may address these shortcomings and promote situation awareness, a prerequisite for good decision making.

OBJECTIVE

The spatial distribution of visual attention is a fundamental process for achieving adequate situation awareness and thus a potential quantifiable surrogate for situation awareness. Moreover, measuring visual attention with a head-mounted eye-tracker may provide insights into usage and acceptance of the new avatar-based patient monitoring modality.

METHODS

This prospective eye-tracking study compared anesthesia providers' visual attention on conventional and avatar-based patient monitors during simulated critical anesthesia events. We defined visual attention, measured as fixation count and dwell time, as our primary outcome. We correlated visual attention with the potential confounders: performance in managing simulated critical anesthesia events (task performance), work experience, and profession. We used mixed linear models to analyze the results.

RESULTS

Fifty-two teams performed 156 simulations. After a manual quality check of the eye-tracking footage, we excluded 57 simulations due to technical problems and quality issues. Participants had a median of 198 (IQR 92.5 - 317.5) fixations on the patient monitor with a median dwell time of 30.2 (IQR 14.9 - 51.3) seconds. We found no significant difference in participants' visual attention when using avatar-based patient monitoring or conventional patient monitoring. However, we found that with each percentage point of better task performance, the number of fixations decreased by about 1.39 (coefficient -1.39; 95%CI: -2.44 to -0.34; P=.02), and the dwell time diminished by 0.23 seconds (coefficient -0.23; 95%CI: -0.4 to -0.06; P=.01).

CONCLUSIONS

Using eye-tracking, we found no significant difference in visual attention when anesthesia providers used avatar-based monitoring or conventional patient monitoring in simulated critical anesthesia events. However, we identified visual attention in conjunction with task performance as a surrogate for situational awareness.

CLINICALTRIAL

Business Management System for Ethics Committees Number Req-2020-00059.

User perceptions of different monitor modalities during high-fidelity simulation: Visual-Patient-avatar, Split Screen and Conventional - a semiquantitative analysis

Background

Patient safety during anesthesia is crucially dependent on the monitoring of vital signs. However, the values obtained must also be perceived and correctly classified by the attending care providers. To facilitate these processes, we developed Visual-Patient-avatar, an animated virtual model of the monitored patient, which innovatively presents numerical and waveform data following user-centered design principles. After a high-fidelity simulation study, we analyzed the participants’ perceptions of 3 different monitor modalities, including this newly introduced technique.

Objective

The aim of this study was to collect and evaluate participants’ opinions and experiences regarding 3 different monitor modalities, which are Visual-Patient-avatar, Split Screen (avatar and Conventional monitor alongside each other), and Conventional monitor after using them during simulated critical anesthetic events.

Methods

This study was a researcher-initiated, single-center, semiquantitative study. We asked 92 care providers right after finishing 3 simulated emergency scenarios about their positive and negative opinions concerning the different monitor modalities. We processed the field notes obtained and derived the main categories and corresponding subthemes following qualitative research methods.

Results

We gained a total of 307 statements. Through a context-based analysis, we identified the 3 main categories of “Visual-Patient-avatar,” “Split Screen,” and “Conventional monitor” and divided them into 11 positive and negative subthemes. We achieved substantial interrater reliability in assigning the statements to 1 of the topics. Most of the statements concerned the design and usability features of the avatar or the Split Screen mode.

Conclusions

This study semiquantitatively reviewed the clinical applicability of the Visual-Patient-avatar technique in a high-fidelity simulation study and revealed the strengths and limitations of the avatar only and Split Screen modality. In addition to valuable suggestions for improving the design, the requirement for training prior to clinical implementation was emphasized. The responses to the Split Screen suggest that this symbiotic modality generates better situation awareness in combination with numerical data and accurate curves. As a subsequent development step, a real-life introduction study is planned, where we will test the avatar in Split Screen mode under actual clinical conditions.

Decision Making in Obstetric Anesthesia

Obstetric anesthesiologists provide care under unique conditions, where frequently unscheduled cases demand flexibility in thinking and acting. And although most obstetric patients may be healthy, they can quickly deteriorate, necessitating rapid team diagnostic and treatment interventions. Examining decision making is a critical step in improving care to these patients. This article reviews evidence-based models of decision making both with individuals and with teams, and presents strategies to improve decision making under any circumstance.

Situational Awareness: Forecasting Successful Military Medical Teams

INTRODUCTION

Military healthcare providers working in military interprofessional healthcare teams (MIHTs) require situational awareness (SA) to ensure safe and efficacious patient care. This study aimed to explore SA in MIHTs to understand how SA can be reinforced and maintained in MIHTs. The research team set out to answer two questions: "What aspects of individual and team SA are particularly important for MIHTs?" and "How can we enable military healthcare providers to be effective MIHTs members with robust SA?".

METHODS

This study used Grounded Theory methodology collecting perspectives from 30 study participants from various backgrounds, including 11 different healthcare professions from the U.S. Army, Air Force, and Navy. Each study participant had experiences participating in, leading one, or leading many MIHTs. Data were collected in three cycles and analyzed within each cycle until saturation was reached.

RESULTS

Five themes were robustly represented in the data set regarding SA: (1) contextually informed adaptability, (2) readiness, (3) trust, (4) communication, and (5) mission focus.

CONCLUSIONS

The urgency often faced by MIHTs brings SA and the principles that underpin SA into sharper focus. The SA themes identified in this research may provide insight into training effectiveness, team strengths and weaknesses, and team performance.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

A protocol implementation to determine aspiration risk in patients with multiple risk factors for gastroparesis

Patients with risk factors for gastroparesis are at increased risk for aspiration into the tracheobronchial tree. Current American Society of Anesthesiologists fasting guidelines use subjective measures to determine aspiration risk. A gastric ultrasound protocol can identify patients with risk factors for gastroparesis and determine the need to perform a point-of-care gastric ultrasound to objectively assess gastric antral contents. This enables the anaesthesia provider to assess patients at increased risk for aspiration. Additionally, many patients who present for surgery with risk factors for gastroparesis have an empty gastric antrum. Thus, the gastric ultrasound protocol checklist saves time and manpower requirements of anaesthesia staff without impacting patient safety or perioperative efficiency. A convenience sample of 40 patients consented for surgery was assessed using a screening tool to identify those at risk for gastroparesis and possible aspiration. Patients deemed at risk received a gastric ultrasound examination to evaluate for the presence of gastric contents. Over 12% of these patients had solid food gastric contents on exam. All patients with solid food gastric contents had an American Society of Anesthesiologists Physical Status Classification of 3 or higher, and two or more risk factors for gastroparesis.

Do team and task performance improve after training situation awareness? A randomized controlled study of interprofessional intensive care teams

Background

When working in complex environments with critically ill patients, team performance is influenced by situation awareness in teams. Moreover, improved situation awareness in the teams will probably improve team and task performance. The aim of this study is to evaluate an educational programme on situation awareness for interprofessional teams at the intensive care units using team and task performance as outcomes.

Method

Twenty interprofessional teams from the northern part of Sweden participated in this randomized controlled intervention study conducted in situ in two intensive care units. The study was based on three cases (cases 0, 1 and 2) with patients in a critical situation. The intervention group (n = 11) participated in a two-hour educational programme in situation awareness, including theory, practice, and reflection, while the control group (n = 9) performed the training without education in situation awareness. The outcomes were team performance (TEAM instrument), task performance (ABCDE checklist) and situation awareness (Situation Awareness Global Assessment Technique (SAGAT)). Generalized estimating equation were used to analyse the changes from case 0 to case 2, and from case 1 to case 2.

Results

Education in situation awareness in the intervention group improved TEAM leadership (p = 0.003), TEAM task management (p = 0.018) and TEAM total (p = 0.030) when comparing cases 1 and 2; these significant improvements were not found in the control group. No significant differences were observed in the SAGAT or the ABCDE checklist.

Conclusions

This intervention study shows that a 2-h education in situation awareness improved parts of team performance in an acute care situation. Team leadership and task management improved in the intervention group, which may indicate that the one or several of the components in situation awareness (perception, comprehension and projection) were improved. However, in the present study this potential increase in situation awareness was not detected with SAGAT. Further research is needed to evaluate how educational programs can be used to increase situation awareness in interprofessional ICU teams and to establish which components that are essential in these programs.

Trial registration

This randomized controlled trial was not registered as it does not report the results of health outcomes after a health care intervention on human participants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00878-2.

Using Eye Tracking for Measuring Cognitive Workload During Clinical Simulations: Literature Review and Synthesis

High-fidelity clinical simulations can be used by clinicians to acquire technical (physical ability and knowledge) and non-technical (cognitive and social processes) skills. Excessive cognitive workload contributes to medical errors because of the impact on both technical and non-technical skills. Many studies measure cognitive workload with psychometric instruments that limit the assessment of cognitive workload to a single time period and may involve response bias. Using eye tracking to measure task-evoked pupillary responses allows the measurement of changes in pupil diameter related to the cognitive workload associated with a specific activity. Incorporating eye tracking with high-fidelity clinical simulations provides a reliable and continuous assessment of cognitive workload. The purpose of this literature review is to summarize the use of eye-tracking technology to measure cognitive workload of healthcare providers to generate evidence-based guidelines for measuring cognitive workload during high-fidelity clinical simulations. What this manuscript adds to the body of literature is a summary of best practices related to the different methods of measuring cognitive workload, benefits and limitations of using eye tracking, and high-fidelity clinical simulation design considerations for successful integration of eye tracking.

Avatar-based patient monitoring in critical anaesthesia events: a randomised high-fidelity simulation study

BACKGROUND

Failures in situation awareness cause two-thirds of anaesthesia complications. Avatar-based patient monitoring may promote situation awareness in critical situations.

METHODS

We conducted a prospective, randomised, high-fidelity simulation study powered for non-inferiority. We used video analysis to grade anaesthesia teams managing three 10 min emergency scenarios using three randomly assigned monitoring modalities: only conventional, only avatar, and split-screen showing both modalities side by side. The primary outcome was time to performance of critical tasks. Secondary outcomes were time to verbalisation of vital sign deviations and the correct cause of the emergency, perceived workload, and usability. We used mixed Cox and linear regression models adjusted for various potential confounders. The non-inferiority margin was 10%, or hazard ratio (HR) 0.9.

RESULTS

We analysed 52 teams performing 154 simulations. For performance of critical tasks during a scenario, split-screen was non-inferior to conventional (HR=1.13; 95% confidence interval [CI], 0.96-1.33; not significant in test for superiority); the result for avatar was inconclusive (HR=0.98; 95% CI, 0.83-1.15). Avatar was associated with a higher probability for verbalisation of the cause of the emergency (HR=1.78; 95% CI, 1.13-2.81; P=0.012). We found no evidence for a monitor effect on perceived workload. Perceived usability was lower for avatar (coefficient=-23.0; 95% CI, -27.2 to -18.8; P<0.0001) and split-screen (-6.7; 95% CI, -10.9 to -2.4; P=0.002) compared with conventional.

CONCLUSIONS

This study showed non-inferiority of split-screen compared with conventional monitoring for performance of critical tasks during anaesthesia crisis situations. The patient avatar improved verbalisation of the correct cause of the emergency. These results should be interpreted considering participants' minimal avatar but extensive conventional monitoring experience.

The "Difficult Learner" in anesthesiology: Challenges, pitfalls, and recommendations

Struggling learners often require interventions that are time-consuming and emotionally exhausting for both the trainee and faculty. Numerous barriers, including lack of resources, faculty development, and fear of legal retribution, can impede medical educators from developing and implementing robust remediation plans. Despite the large volume of literature citing professionalism education and the "hidden curriculum" as problem areas in medical education, frontline educators lack practical tools and empowerment to address unprofessionalism in trainees. The paucity of resources in this arena has led to decreased job satisfaction, increased burnout, and an exodus from academic medicine. Department leadership acknowledgment and investment in training faculty on remediation strategies for learners in difficulty and providing tools to meet these challenging job demands will improve faculty's job satisfaction and overall well-being. The authors review salient literature and methodology for diagnosing learners in difficulty, with focus on a high-yield, pragmatic approach that can be taken by medical training programs, including those that lack a robust medical education infrastructure.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association

Purpose

We analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern.

Methods

We included all airway-related civil legal cases involving specialist anesthesiologists that closed from 2007 to 2016. The following variables were abstracted by CMPA medical analysts: clinical context, peer expert opinions of contributing factors, and patient and legal outcomes.

Results

We found 46 of the 406 (11%) closed cases involving anesthesiologists to be airway-related. Twenty-six cases (57%) involved elective surgery and 31 patients (67%) were categorized as American Society of Anesthesiologists physical status III. Twenty-five cases (54%) occurred outside the operating room (e.g., postanesthesia care unit, intensive care unit, or other satellite locations). In 19 (42%) cases, there was at least one predictor of a difficult airway. Peer experts identified judgement failures in 30 cases (65%), most commonly inadequate airway evaluation. In 30 cases (65%), the patient died or had a permanent brain injury. The medicolegal outcome favoured the patient in 27 (59%) cases, with a median [interquartile range] payment of 422,845 [257,637-935,673] CAD.

Conclusions

Severe patient harm is common when airway management is the focus of a CMPA medicolegal complaint involving anesthesiologists. Patients were otherwise typically low risk cases presenting for elective surgery. Failure to assess or to change management based on the airway exam or encountered difficulty were the most common errors. Our findings support the continued need for adoption, adherence, and practice of guidelines for anticipated and unanticipated difficult airway management for every patient encounter.

Validation of the Raw National Aeronautics and Space Administration Task Load Index (NASA-TLX) Questionnaire to Assess Perceived Workload in Patient Monitoring Tasks: Pooled Analysis Study Using Mixed Models

Background

Patient monitoring is indispensable in any operating room to follow the patient’s current health state based on measured physiological parameters. Reducing workload helps to free cognitive resources and thus influences human performance, which ultimately improves the quality of care. Among the many methods available to assess perceived workload, the National Aeronautics and Space Administration Task Load Index (NASA-TLX) provides the most widely accepted tool. However, only few studies have investigated the validity of the NASA-TLX in the health care sector.

Objective

This study aimed to validate a modified version of the raw NASA-TLX in patient monitoring tasks by investigating its correspondence with expected lower and higher workload situations and its robustness against nonworkload-related covariates. This defines criterion validity.

Methods

In this pooled analysis, we evaluated raw NASA-TLX scores collected after performing patient monitoring tasks in four different investigator-initiated, computer-based, prospective, multicenter studies. All of them were conducted in three hospitals with a high standard of care in central Europe. In these already published studies, we compared conventional patient monitoring with two newly developed situation awareness–oriented monitoring technologies called Visual Patient and Visual Clot. The participants were resident and staff anesthesia and intensive care physicians, and nurse anesthetists with completed specialization qualification. We analyzed the raw NASA-TLX scores by fitting mixed linear regression models and univariate models with different covariates.

Results

We assessed a total of 1160 raw NASA-TLX questionnaires after performing specific patient monitoring tasks. Good test performance and higher self-rated diagnostic confidence correlated significantly with lower raw NASA-TLX scores and the subscores (all P<.001). Staff physicians rated significantly lower workload scores than residents (P=.001), whereas nurse anesthetists did not show any difference in the same comparison (P=.83). Standardized distraction resulted in higher rated total raw NASA-TLX scores (P<.001) and subscores. There was no gender difference regarding perceived workload (P=.26). The new visualization technologies Visual Patient and Visual Clot resulted in significantly lower total raw NASA-TLX scores and all subscores, including high self-rated performance, when compared with conventional monitoring (all P<.001).

Conclusions

This study validated a modified raw NASA-TLX questionnaire for patient monitoring tasks. The scores obtained correctly represented the assumed influences of the examined covariates on the perceived workload. We reported high criterion validity. The NASA-TLX questionnaire appears to be a reliable tool for measuring subjective workload. Further research should focus on its applicability in a clinical setting.

Haematoma, abscess or meningitis after neuraxial anaesthesia in the USA and the Netherlands: A closed claims analysis

BACKGROUND

Severe complications after neuraxial anaesthesia are rare but potentially devastating.

OBJECTIVE

We aimed to identify characteristics and preventable causes of haematoma, abscess or meningitis after neuraxial anaesthesia.

DESIGN

Observational study, closed claims analysis.

SETTING

Closed anaesthesia malpractice claims from the USA and the Netherlands were examined from 2007 until 2017.

PATIENTS

Claims of patients with haematoma (n = 41), abscess (n = 18) or meningitis (n = 14) associated with neuraxial anaesthesia for labour, acute and chronic pain that initiated and closed between 2007 and 2017 were included. There were no exclusions.

MAIN OUTCOME MEASURES

We analysed potential preventable causes in patient-related, neuraxial procedure-related, treatment-related and legal characteristics of these complications.

RESULTS

Patients experiencing spinal haematoma were predominantly above 60 years of age and using antihaemostatic medication, whereas patients with abscess or meningitis were middle-aged, relatively healthy and more often involved in emergency interventions. Potential preventable causes of unfavourable sequelae constituted errors in timing/prescription of antihaemostatic medication (10 claims, 14%), unsterile procedures (n = 10, 14%) and delay in diagnosis/treatment of the complication (n = 18, 25%). The number of claims resulting in payment was similar between countries (USA n = 15, 38% vs. the Netherlands n = 17, 52%; P = 0.25). The median indemnity payment, which the patient received varied widely between the USA (&OV0556;285 488, n = 14) and the Netherlands (&OV0556;31 031, n = 17) (P = 0.004). However, the considerable differences in legal systems and administration of expenses between countries may make meaningful comparison of indemnity payments inappropriate.

CONCLUSIONS

Claims of spinal haematoma were often related to errors in antihaemostatic medication and delay in diagnosis and/or treatment. Spinal abscess claims were related to emergency interventions and lack of sterility. We wish to highlight these potential preventable causes, both when performing the neuraxial procedure and during postprocedural care of patients.

Airway Leads and Airway Response Teams: Improving Delivery of Safer Airway Management?

Purpose of Review

Airway management remains a source of significant morbidity and mortality. This review considers recent summaries of complications and looks toward strategies to improve practice using a coordinated approach.

Recent Findings

A safety gap can exist between national recommendations and local practice. A lack of attention to end tidal carbon dioxide has repeatedly contributed to airway mismanagement. Clinicians must be trained in newer airway devices (videolaryngoscopes or supraglottic airways) to use them effectively. Time must be found to teach rarely performed skills (e.g., front-of-neck access). Both larger and smaller hospitals have benefitted from an airway lead or response team, coordinating education programs, ensuring the adoption of guidelines, standardizing equipment, and recognizing the role of human factors and ergonomics.

Summary

Even in the twenty-first century, the incidence of airway-related morbidity and mortality can be reduced, by an institutionally supported, coordinated approach to the whole process of airway care.

Cognitive States Matter: Design Guidelines for Driving Situation Awareness in Smart Vehicles

Situation awareness (SA) is crucial for safe driving. It is all about perception, comprehension of current situations and projection of the future status. It is demanding for drivers to constantly maintain SA by checking for potential hazards while performing the primary driving tasks. As vehicles in the future will be equipped with more sensors, it is likely that an SA aiding system will present complex situational information to drivers. Although drivers have difficulty to process a variety of complex situational information due to limited cognitive capabilities and perceive the information differently depending upon their cognitive states, the well-known SA design principles by Endsley only provide general guidelines. The principles lack detailed guidelines for dealing with limited human cognitive capabilities. Cognitive capability is a mental capability including planning, complex idea comprehension, and learning from experience. A cognitive state can be regarded as a condition of being (e.g., the state of being aware of the situation). In this paper, we investigate the key cognitive attributes related to SA in driving contexts (i.e., attention focus, mental model, workload, and memory). Endsley proposed that those key cognitive attributes are the main factors that influence SA. In those with higher levels of attributes, we found eight cognitive states which mainly influence a human driver in achieving SA. These are the focused attention state, inattentional blindness state, unfamiliar situation state, familiar situation state, insufficient mental resource state, sufficient mental resource state, high time pressure state, and low time pressure state. We then propose cognitive state aware SA design guidelines that can help designers to effectively convey situation information to drivers. As a case study, we demonstrated the usefulness of our cognitive state aware SA design guidelines by conducting controlled experiments where an existing SA interface is compared with a new SA interface designed following the key guidelines. We used the Situation Awareness Global Assessment Technique (SAGAT) and Decision-Making Questionnaire (DMQ) to measure the SA and decision-making style scores, respectively. Our results show that the new guidelines allowed participants to achieve significantly higher SA and exhibit better decision making performance.

Educational Interventions to Enhance Situation Awareness: A Systematic Review and Meta-Analysis

STATEMENT

We conducted a systematic review to evaluate the comparative effectiveness of educational interventions on health care professionals' situation awareness (SA). We searched MEDLINE, CINAHL, HW Wilson, ERIC, Scopus, EMBASE, PsycINFO, psycARTICLES, Psychology and Behavioural Science Collection and the Cochrane library. Articles that reported a targeted SA intervention or a broader intervention incorporating SA, and an objective outcome measure of SA were included. Thirty-nine articles were eligible for inclusion, of these 4 reported targeted SA interventions. Simulation-based education (SBE) was the most prevalent educational modality (31 articles). Meta-analysis of trial designs (19 articles) yielded a pooled moderate effect size of 0.61 (95% confidence interval = 0.17 to 1.06, P = 0.007, I = 42%) in favor of SBE as compared with other modalities and a nonsignificant moderate effect in favor of additional nontechnical skills training (effect size = 0.54, 95% confidence interval = 0.18 to 1.26, P = 0.14, I = 63%). Though constrained by the number of articles eligible for inclusion, our results suggest that in comparison with other modalities, SBE yields better SA outcomes.

Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research

Visual Patient technology is a situation awareness-oriented visualization technology that translates numerical and waveform patient monitoring data into a new user-centered visual language. Vital sign values are converted into colors, shapes, and rhythmic movements-a language humans can easily perceive and interpret-on a patient avatar model in real time. In this review, we summarize the current state of the research on the Visual Patient, including the technology, its history, and its scientific context. We also provide a summary of our primary research and a brief overview of research work on similar user-centered visualizations in medicine. In several computer-based studies under various experimental conditions, Visual Patient transferred more information per unit time, increased perceived diagnostic certainty, and lowered perceived workload. Eye tracking showed the technology worked because of the way it synthesizes and transforms vital sign information into new and logical forms corresponding to the real phenomena. The technology could be particularly useful for improving situation awareness in settings with high cognitive demand or when users must make quick decisions. This comprehensive review of Visual Patient research is the foundation for an evaluation of the technology in clinical applications, starting with a high-fidelity simulation study in early 2020.

The Mechanisms Responsible for Improved Information Transfer in Avatar-Based Patient Monitoring: Multicenter Comparative Eye-Tracking Study

Background

Patient monitoring is central to perioperative and intensive care patient safety. Current state-of-the-art monitors display vital signs as numbers and waveforms. Visual Patient technology creates an easy-to-interpret virtual patient avatar model that displays vital sign information as it would look in a real-life patient (eg, avatar changes skin color from healthy to cyanotic depending on oxygen saturation). In previous studies, anesthesia providers using Visual Patient perceived more vital signs during short glances than with conventional monitoring.

Objective

We aimed to study the deeper mechanisms underlying information perception in conventional and avatar-based monitoring.

Methods

In this prospective, multicenter study with a within-subject design, we showed 32 anesthesia providers four 3- and 10-second monitoring scenarios alternatingly as either routine conventional or avatar-based in random sequence. All participants observed the same scenarios with both technologies and reported the vital sign status after each scenario. Using eye-tracking, we evaluated which vital signs the participants had visually fixated (ie, could have potentially read and perceived) during a scenario. We compared the frequencies and durations of participants’ visual fixations of vital signs between the two technologies.

Results

Participants visually fixated more vital signs per scenario in avatar-based monitoring (median 10, IQR 9-11 versus median 6, IQR 4-8, P<.001; median of differences=3, 95% CI 3-4). In multivariable linear regression, monitoring technology (conventional versus avatar-based monitoring, difference=−3.3, P<.001) was an independent predictor of the number of visually fixated vital signs. The difference was less prominent in the longer (10-second) scenarios (difference=−1.5, P=.04). Study center, profession, gender, and scenario order did not influence the differences between methods. In all four scenarios, the participants visually fixated 9 of 11 vital signs statistically significantly longer using the avatar (all P<.001). Four critical vital signs (pulse rate, blood pressure, oxygen saturation, and respiratory rate) were visible almost the entire time of a scenario with the avatar; these were only visible for fractions of the observations with conventional monitoring. Visual fixation of a certain vital sign was associated with the correct perception of that vital sign in both technologies (avatar: phi coefficient=0.358; conventional monitoring: phi coefficient=0.515, both P<.001).

Conclusions

This eye-tracking study uncovered that the way the avatar-based technology integrates the vital sign information into a virtual patient model enabled parallel perception of multiple vital signs and was responsible for the improved information transfer. For example, a single look at the avatar’s body can provide information about: pulse rate (pulsation frequency), blood pressure (pulsation intensity), oxygen saturation (skin color), neuromuscular relaxation (extremities limp or stiff), and body temperature (heatwaves or ice crystals). This study adds a new and higher level of empirical evidence about why avatar-based monitoring improves vital sign perception compared with conventional monitoring.