Year : 2023 | Volume
| Issue : 1 | Page : 1-6
Efficacy of in-situ simulation training using evaluation checklists for sudden oxygen supply failure during general anesthesia: A preliminary report
Keisuke Nishida1, Fumio Watanabe1, Taiki Kojima2
1 Department of Anesthesiology, Aichi Children's Healthy and Medical Center, Obu-City, Aichi, Japan
2 Department of Anesthesiology, Aichi Children's Healthy and Medical Center, Obu-City, Aichi; Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Aichi, Japan
Department of Anesthesiology, Aichi Children's Health and Medical Center 426 Nana-Chome, Morioka-Cho, Obu-City Aichi 478-8710
Source of Support: None, Conflict of Interest: None
|Date of Submission||23-Jul-2022|
|Date of Acceptance||05-Aug-2022|
|Date of Web Publication||02-Jan-2023|
Introduction: Sudden oxygen supply failure (OSF) is a life-threatening consequence that may be triggered by natural disasters. Anesthesiologists are required to manage OSF promptly in such catastrophic situations. However, the current evidence regarding the efficacy of anesthesia training for sudden OSF is insufficient. This preliminary study aimed to introduce our in-situ simulation training utilizing evaluation checklists for a sudden OSF situation during general anesthesia and to evaluate the efficacy of the training program for anesthesia providers.
Methods: This is a preliminary single-center, prospective study. We developed an OSF simulation scenario utilizing evaluation checklists with key actions to manage OSF. The training session comprised four components: orientation, benchmark evaluation (pre-test) according to the checklists, a short didactic lecture, and post-lecture evaluation (post-test). The scenario comprised two steps wherein the participants were supposed to utilize different oxygen supply sources immediately after OSF (Step 1) and minimize the amount of oxygen consumption (Step 2).
Results: Fifteen anesthesia providers were enrolled. The score for all anesthesia providers in the post-test was significantly higher than that in the pre-test (median 8 [IQR: 8, 8], 3 [IQR: 3, 4], P < 0.001, respectively). The successful performance rates of all anesthesia providers in one key action of all the four in Step 1 and four of all the six in Step 2 were significantly higher in the post-test than in the pre-test.
Conclusions: Our in-situ training method utilizing evaluation checklists for a sudden OSF situation improved overall performance of anesthesia providers.
Keywords: General anesthesia, natural disaster, simulation training
|How to cite this article:|
Nishida K, Watanabe F, Kojima T. Efficacy of in-situ simulation training using evaluation checklists for sudden oxygen supply failure during general anesthesia: A preliminary report. Saudi J Anaesth 2023;17:1-6
|How to cite this URL:|
Nishida K, Watanabe F, Kojima T. Efficacy of in-situ simulation training using evaluation checklists for sudden oxygen supply failure during general anesthesia: A preliminary report. Saudi J Anaesth [serial online] 2023 [cited 2023 Mar 31];17:1-6. Available from: https://www.saudija.org/text.asp?2023/17/1/1/364870
| Introduction|| |
Anesthesiologists can encounter catastrophic natural disasters during general anesthesia. These major natural disasters can cause several potential life-threatening consequences including sudden oxygen supply failure (OSF) and/or mechanical failure of the anesthetic machine due to the direct mechanical damages to the equipment. In these situations, anesthesiologists must manage the life-threatening consequences immediately.
Some previous studies introduced the methods of simulation-based training to manage sudden OSF in operating rooms.,,, However, there is still insufficient evidence on the learning efficacy of the training programs for sudden OSF due to natural disasters.
In-situ simulation training is commonly performed in anesthesia education to maximize the learning efficacy of learners by improving their physical, environmental, and psychological fidelity. Moreover, such simulation-based training can provide realistic situational training using institution-specific resources. Therefore, in-situ simulation can be effective in learning situational awareness, crew resource management, and team dynamics. However, the technique of maximizing the learning efficacy to manage “many things to do” in a rapidly progressive scenario is yet to be explored. Therefore, we developed an in-situ simulation training session utilizing evaluation checklists to maximize the learning efficacy of management skills in a rapidly progressive scenario, which comprises two components: 1) in-situ simulation practice and 2) a short didactic lecture using evaluation checklists.
This preliminary study aimed to describe our methodology of the in-situ simulation training using evaluation checklists for sudden OSF during general anesthesia and to evaluate the efficacy of the training program for anesthesia providers.
| Methods|| |
Study design and setting
This preliminary, single-center, prospective study was conducted between November 2021 and January 2022 at Aichi Children's Health and Medical Center, a 200-bed tertiary care children's hospital in Japan. Ethical approval was obtained from the regional ethics committee (Approval number 2021046, August 20, 2021). Anesthesiologists, anesthesia fellows, and pediatric residents were enrolled in this study. All participants provided informed consent for participating in the study.
Simulation of OSF
An OSF simulation scenario and evaluation checklists were created based on a previous review of management of OSF during general anesthesia before initiation of data collection by two research investigators (FW, KN). In the simulation scenario, a study participant was expected to identify sudden OSF immediately after an earthquake that occurred during general anesthesia in the operating room and manage the situation by maintaining the oxygen supply to the patient. During the OSF simulation, participants were evaluated using the predetermined evaluation checklists in situational awareness and management skills for sudden OSF. The simulation session comprised four components: 1) orientation to provide general information regarding the available equipment and the functions of the high-fidelity mannequin and the introduction of the case; 2) benchmark evaluation (pre-test); 3) a short didactic lecture to explain the expected management protocol for anesthesia providers during sudden OSF; and 4) post-lecture evaluation (post-test) using the same evaluation checklists as the pre-test. All participants were strictly prohibited from sharing information regarding the simulation scenario and the contents of the evaluation checklists with other participants. Changes in the vital signs (i.e., blood pressure, heart rate, oxygenation saturation, and end-tidal carbon dioxide concentration) of the high-fidelity mannequin were reflected on a separate monitor (SimBaby®, Laerdal Medical, Stavanger, Norway). The high-fidelity mannequin was intubated and connected to an anesthetic machine from the beginning of the experiment (Aespire View®, GE Healthcare, WY, USA).
Data pertaining to baseline participant characteristics, including sex, years of clinical experience, clinical experience level (i.e., resident, fellow, or attending), and experience of simulation-based training, were collected. The scores for each key action under the OSF scenario were recorded in the evaluation checklists, which were predetermined during the development of the study protocol by one research investigator (KN) [Table 1].
OSF simulation scenario
The patient was a 2-year-old boy with a body weight of 15 kg who was scheduled to undergo an emergency laparotomy for intestinal perforation under general anesthesia. The patient was intubated and mechanically ventilated using an anesthetic machine. Anesthesia was maintained using 100% oxygen and 2% sevoflurane at the beginning of the experiment. Immediately after simulation initiation, a research investigator (FW) told the participants that an enormous earthquake had occurred, and the oxygen and air supply pipelines were disconnected from the outlets on the wall (the entire gas supply was assumed to be interrupted due to pipeline damage caused by the earthquake). An emergency electric power supply was maintained to operate the anesthetic machine.
Two steps in the OSF simulation scenario
The OSF simulation scenario comprised two steps wherein the participants were supposed to identify the insufficient delivery of mechanical ventilation immediately after the occurrence of OSF and utilize different oxygen supply sources (Step 1), and confirm the oxygen supply, minimize the amount of oxygen consumption and maintain anesthesia (Step 2). In Step 1, participants were expected to perform the following actions: 1a) call for help and change the way of ventilation, 1b) initiate bag valve mask ventilation, and 1c) open the oxygen cylinder behind the anesthetic machine. During the development of the study protocol, we determined that 1a), 1b), and 1c) would be the key actions in Step 1 [Figure 1]. We determined two possibilities in the simulation scenario wherein the participants can perform all three key actions (i.e., 1a, 1b, and 1c) regardless of the first action by the participant: Possibility 1: The participant initially starts bag valve mask ventilation on room air after OSF is identified. However, oxygen desaturation persists (SpO2 is maintained at approximately 85%) until the oxygen cylinder is opened. Possibility 2: The participant opens the oxygen cylinder immediately after OSF is identified. However, the participant needs to initiate bag valve mask ventilation once the oxygen cylinder is empty. In Step 2, participants are expected to confirm the presence of adequate oxygen supply from the oxygen cylinder behind the anesthetic machine by checking 2a) the fraction of inspired oxygen on the monitor of the anesthetic machine and 2b) the manometer on the anesthetic machine for determining the oxygen supply pressure. Participants attempted to reduce the amount of oxygen consumed from the oxygen cylinder by 2c) switching to manual ventilation, 2d) reducing the fresh flow of gas (≤1 L/min), and 2e) closing the adjustable pressure-limiting valve. To maintain anesthesia without inhalational anesthetics, participants were expected to 2f) switch to total intravenous anesthesia. Similar to Step 1, we determined that 2a), 2b), 2c), 2d), 2e), and 2f) would be the key actions in Step 2 [Figure 1].
|Figure 1: The protocol for the management of oxygen supply failure (OSF). OSF management comprised two main steps: participants were supposed to ensure patient ventilation immediately after OSF (Step 1), and confirm oxygen supply and save the limited amount of oxygen during OSF (Step 2). Key actions were predetermined in Steps 1 and 2 (1a, 1b, 1c, 2a, 2b, 2c, 2d, 2e, and 2f)|
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Two research investigators (FW and KN) developed the evaluation checklists that evaluated whether the participants performed the predetermined key actions in the simulated OSF scenario. The evaluation checklists were developed by referring to previous literature, and the final version of the checklists were verified through the agreement of two research investigators who had board certifications in anesthesiology from Japan (FW, KN). In the checklists, the participants were scored one point for the successful performance of each key action in Steps 1 and 2 [Table 1]. In Step 1, participants were scored two points if they could successfully restore adequate ventilation within 30 s of OSF, which is the time required for the SpO2 to drop from 100% to 95% after an infant develops apnea. The maximum performance scores in the pre-test and post-test were 10 points each.
Hard-stops in the OSF simulation scenario
Two conditions for the hard stop in the simulation session were predetermined in the study protocol. First, the participants did not start ventilating the mannequin over 60 s after the initiation of OSF (The preset “60 s” was the estimated time required for the SpO2 to drop from 100% to 90% during apnea in a child under 2 years of age). Second, the participants did not perform any new action for over 60 s.
Categorical data were described as numbers and percentages, and non-normally distributed continuous variables were described as medians and interquartile ranges (IQRs). To evaluate the difference in the total performance scores between the pre-test and post-test, a Wilcoxon matched-pairs signed-rank test was applied. For post hoc analysis, the successful performance rate for each key action was compared between pre- and post-tests using McNemar's Chi-square test for matched pairs (pre-and post-tests were performed for each participant). To address the issue of increasing type-1 error by multiple comparisons, the cutoff P value was predetermined by Bonferroni correction. Data were analyzed utilizing STATA 15.1 (StataCorp, College Station, TX, USA), with a two-sided P value of <0.05 for the comparison of total performance scores between pre- and post-tests, and <0.005 for post hoc analysis as the criterion for statistical significance.
| Results|| |
Fifteen anesthesia providers (10 anesthesiologists, 4 fellows, and 1 pediatric resident) were enrolled between November 2021 and December 2021.
Most participants were anesthesiologists, and about half of the participants were not familiar with mannequin-based simulation training (<5 times simulation training experience) [Table 2].
Performance scores in pre- and post-tests
The successful performance rate of each key action in the pre-test was not significantly different between anesthesiologists and others (anesthesia fellows and pediatric resident) [Table 3]. The total performance score for all anesthesia providers in the post-test was significantly higher than that in the pre-test (median 8 [IQR: 8, 8], 3 [IQR: 3, 4], P < 0.001, respectively). The successful performance rates of all anesthesia providers in one key action of all the four in Step 1 and four of all the six in Step 2 were significantly higher in the post-test than in the pre-test [Table 4].
|Table 3: Successful performance rate for each key action in the pre-test according to the participant training level (n=15)|
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| Discussion|| |
This is a prospective study to evaluate the efficacy of in-situ simulation training utilizing evaluation checklists to enhance situational awareness and management skills of anesthesia providers in a sudden OSF scenario during general anesthesia. Our study showed that both pediatric anesthesiologists, anesthesia fellows and pediatric resident were unfamiliar with the emergency management of sudden OSF during general anesthesia. However, our simulation-based training improved the total performance score of all anesthesia providers for sudden OSF.
Simulation-based medical education is accepted as being effective in improving situational awareness and developing optimal management skills in high-stake situations. Miller emphasized the importance of providing simulation training for realistic situations, which can enable optimal actions in high-stake situations. Sudden OSF during general anesthesia is a high-stake situation that requires immediate management of several events by anesthesia providers during the rapidly progressive situation. We believe that evaluation checklists could facilitate learners to focus on several actions which were needed to be undertaken during the short period. This study showed that our in-situ simulation training using evaluation checklists could improve the skills of providing immediate management in the clinical contexts of rapid deterioration.
Previous studies have shown inconsistent results for the number of anesthesiologists who successfully opened the oxygen cylinder in OSF simulation sessions (50-100%)., In our study, all participants immediately initiated bag valve mask ventilation. However, only approximately 40% of the participants requested to open the auxiliary oxygen cylinder behind the anesthetic machine. The American Society of Anesthesiologists' guidelines highlight the importance of pre-anesthesia checkout, which requires opening the auxiliary oxygen cylinder to verify the presence of sufficient amount of oxygen. Our study results suggest that some anesthesia providers might not have been familiar with the method of opening the auxiliary oxygen cylinder. Moreover, reducing the amount of oxygen consumption is essential during OSF management since an auxiliary cylinder might not be adequate for supplying oxygen to a patient for several hours. However, the successful performance rate of reducing the amount of oxygen consumption in the pre-test was low in the pre-test. The post-test performance scores of these learners in both items were improved after in-situ simulation training. The optimal management of critical situations required several steps, such as situational awareness, information integration, and resource identification. In this regard, in-situ simulation training providing a short lecture using evaluation checklists might be effective in reminding anesthesia providers the fundamental process to manage high-stakes situations.
Our study showed the necessity of simulation-based training for OSF management and the efficacy of learning optimal management for anesthesia providers. However, anesthesia providers may encounter other catastrophic situations, including power outages and fires in operating rooms. The evidence to address the necessity and efficacy of in-situ simulation training for multiple life-threatening consequences occurring simultaneously in natural disasters is limited. Anesthesia providers should have the specific knowledge and provide appropriate management in such critical situations. For instance, anesthesia providers should know the duration for which the internal electric power source is supposed to be maintained after institutional power outages and the further management protocol. In addition, deliberate in situ practice might be necessary to improve the skills of surgical team members for coping with challenging situations. An in-situ simulation program presumes multiple consequences that occur simultaneously where the anesthesia providers must prioritize the things to do during the short period. Further explorations are required to develop such training programs with high validity.
This preliminary study had several limitations. First, the sample size was small, though statistically significant improvement in most essential key actions because of simulation-based training was evident. Second, this study was conducted at a single institution; thus, our results cannot be generalized to other institutions. Further multicenter prospective studies are required. Third, the validity of the evaluation checklists was not assessed in this study. Therefore, further validation studies are required. In this study, to minimize the bias in developing the evaluation checklists, two board-certified anesthesiologists carefully discussed the key actions that may be performed by anesthesia providers during sudden OSF scenario according to previous reviews in the field of anesthesiology, and decided the key items through agreement. Finally, the learning period for mastering the OSF training was not explored and requires further investigation to clarify the optimal training interval.
| Conclusion|| |
This preliminary prospective study showed that in-situ simulation training utilizing evaluation checklists for anesthesia providers in a sudden OSF scenario improved their overall performance. However, further investigations are needed to explore the validity of the evaluation checklists and improve the generalizability of the study results.
We would like to thank Enago (www.enago.jp) for the English language review.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]