Chapter 129

2128 PART 6 ■ Specific Considerations
patient risk. Scenarios can be flexibly constructed, with a range of
difficulty appropriate for both the novice and expert clinician.
Participants can see the results of their decisions and actions
immediately, and errors can be allowed to occur and reach their
conclusion. High-fidelity simulation frequently takes place in a
realistic environment with actual medical equipment, exposing
technical problems and systemic failures that diminish the
effectiveness of patient care. Simulation can explore interpersonal
interactions and offers training opportunities in teamwork,
leadership and communication. In addition, all simulated sessions
can be recorded without concern for patient confidentiality and
stored for later evaluation.
Several studies have demonstrated practice improvement
following participation in simulation training. Rosenthal showed
that significant improvement in basic airway management after
simulation persisted 6 weeks after initial training and with
subsequent patient encounters. 58 When medical students were
randomized to either simulation-based training or problem based
learning in management of critical respiratory events, Steadman
demonstrated that clinical performance was enhanced in the
simulation group. 59 In teams previously trained in ACLS, DeVita
described how simulation training improved team performance,
which dramatically increased the likelihood of successful resuscitation.
60
Early career development in high-risk fields such as medicine
emphasizes the acquisition of “technical” ability, in which simulation
can play an important role. After achieving appropriate skill
levels, training shifts to include more “nontechnical” aspects of
patient care, including teamwork, situational awareness, and
decision-making. The concept of teamwork training is thoroughly
integrated into the aviation industry, where it is known as crew
resource management (CRM). When the aviation industry discovered
that 70% of aircraft accidents were due to pilot error, 61 it
modified its safety training to include a focus on effective flight
deck team performance and communication. As anesthesiologists,
despite our daily teamwork with nurses, surgeons, and other
health care professionals, our training historically has focused on
individual rather than team performance. Many authors have
recognized that teamwork training should be incorporated into
anesthesia practice, including Gaba, who pioneered the adoption of
CRM concepts into anesthesiology. His Anesthesia Crisis Resource
Management course serves as a model for multidisciplinary team
training in simulated operating rooms. Because effective teamwork
training has led to improved safety in aviation, we believe that it
will enhance patient outcomes in medicine as well.
Despite simulation’s tremendous potential to improve physician
performance, there is reluctance to use it as an assessment tool. 62
Concerns include its expense, its lack of “fidelity,” the threatening
nature of the simulation environment, and the lack of evidence of
its assessment validity. Utilizing medical simulation for physician
assessment will require the development of validated methodologies
that demonstrate the effectiveness of simulation training,
including the identification of key behaviors that result in suboptimal
outcomes. One such tool has been investigated by Fletcher
and Flin, 63 whose Anaesthetists’ Non-Technical Skills system
describes an approach to performance measurement that is highly
relevant to our practice 64 (Table 129–11). This assessment methodology
is limited by its complexity and labor intensity.
In some countries, simulation is in its early stages of being used
as a credentialing tool in anesthesiology. In New Zealand, board
certification requires the participation in one of two simulation
TABLE 129-11. Anaesthesia Non-Technical Skills
(ANTS) System: Categories, Elements, and Rating Scale
1) Task management: Skills for organizing resources and
required activities to achieve goals be they individual case
plans or longer term scheduling issues.
a) Planning and preparing.
b) Prioritizing.
c) Providing and maintaining standards.
d) Identifying and utilizing resources.
2) Team-working: Skills for working in a group context, in any
role, to ensure effective joint task completion and team
member satisfaction; the focus is particularly on the team
rather than the task.
a) Coordinating activities with team members.
b) Exchanging information.
c) Using authority and assertiveness.
d) Assessing capabilities.
d) Supporting others.
3) Situational awareness: Skills for developing and maintaining
an overall awareness of the work setting based on observing
all relevant aspects of the theatre environment (patient, team,
time, displays, equipment); understanding what they mean,
and thinking ahead about what could happen next.
a) Gathering information.
b) Recognizing and understanding.
c) Anticipating.
4) Decision-making: Skills for reaching a judgment to select a
course of action or make a diagnosis about a situation, in
both normal conditions and in time-pressured crisis
situations.
a) Identifying options.
b) Balancing risks and selecting options.
c) Reevaluating.
Rating:
4 - Good Performance was of a consistently high
standard, enhancing patient safety. It could be
used as a positive example for others.
3 - Acceptable Performance was of a satisfactory standard
but could be improved.
2 - Marginal Performance indicated cause for concern.
Considerable improvement is needed.
1 - Poor Performance endangered or potentially
endangered patient safety. Serious
remediation is required.
Not observed Skill could not be observed in this scenario.
Reproduced with permission from Flin (reference 72).
courses: Effective Management of Anesthetic Crises (EMAC) or
Early Management of Severe Trauma (EMST). 65 Simulation is also
a prerequisite for Israeli oral board examination. 66 In the U.S., the
American Board of Anesthesiology is developing its simulation
infrastructure and will incorporate simulation-based learning into
its recertification programs. 67
Simulation in Pediatric Anesthesiology
High-fidelity simulation is also becoming an important educational
tool in pediatric anesthesiology. Expert care of the pediatric
patient in the operating room, intensive care unit or emergency