AAGBI/Anaesthesia Small Research Grant
A simulator based randomised comparison of national guidelines for local anaesthetic toxicity versus modified versions
Dr Matthew Mackenzie
Local anaesthetic drugs are widely used in many procedures in an operating theatre and in other settings throughout the hospital. Overdose or inappropriate administration of local anaesthetic is rare but can result in serious complications with adverse effects on heart, nerve and brain tissue. Such effects can lead to seizures and cardiac arrest.
Due to the serious nature of such complications, national guidelines for their treatment have been published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI). These guidelines involve the use of a lipid emulsion. This is the same fluid as is used for intravenous nutrition for patients who cannot eat. The emulsion is delivered intravenously to the patient as a dose delivered over a minute, known as a bolus, followed by a continuous infusion. All these doses are calculated using the weight of the patient. A life-like computer controlled manikin that resembles and recreates the symptoms and signs of a live patient is often used for training anaesthetists to use these guidelines. During such training, we observed that many teams struggled to faithfully follow the AAGBI guidelines and did not administer the required doses of the emulsion. This highlights the potential for significant delay in initiating lifesaving treatment if translated to real clinical situations. We postulate that during stressful situations, the extra cognitive load required to organise delivery of the lipid emulsion as boluses and continuous infusions, may impede timeliness.
We hypothesise that a version of guidelines that removes the need for a continuous infusion and instead uses repeated single bolus doses would lead to faster administration of treatment. This "bolus only" method may better approximate the "bolus plus infusion" method in a real world situation.
The visual layout of guidelines intended for infrequent emergency scenarios should be designed to improve ease of use so that treatment is not delayed. An American equivalent of the AAGBI called ASRA also produce national guidelines but they are laid out in a way that may make them hard to follow with small fonts, use of bullet points, lack of colour and no diagrams. In contrast, the AAGBI guidelines are well laid out with clear lines, a readable font and a good use of colour and shade.
Our secondary aim is to show that if the AAGBI guidelines were presented in an ASRA style format they would be harder to follow.
We will recruit anaesthetists to our study and use a manikin to run a mock situation of local anaesthetic overdose. Participants will be given one of three guidelines; the original AAGBI version, a "bolus only" version presented in the AAGBI layout, or a version that delivers the same information as the original but using an ASRA style layout. We will collect data from each candidate such as the quantity of drug given over time and also how quickly other specific tasks are completed as an indicator of
how easy each version is to follow. The different guidelines will then be compared
using appropriate statistical tests.
Does repeating a scenario after debriefing, in anaesthetic simulation training, improve acquisition on non-technical skills?
Dr H Reynolds
Jointly funded with the Society for Education in Anaesthesia, UK
Aims
The aim of this study is to compare the acquisition of non-technical skills between a simulation design with a repeated scenario and a design with a traditional single scenario.
Research questions:
(1) Does a repetitive scenario simulation design (15 minute scenario, 20 minute debrief, 10 minute re-run first scenario) lead to demonstration of greater Anaesthetic Non-Technical Skills on a new scenario, compared with a single scenario design (15 minute scenario, 30 minute debrief)?
(2) Do trainees give higher feedback ratings on the repetitive scenario protocol compared with a single scenario protocol?
(3) Do trainees find a repetitive scenario an acceptable way to learn as measured by a semi-structured interview?
Background
Studies show repeating a surgical procedure improves technical skills. A recent study showed repetition of paediatric resuscitation scenarios after debriefing, led to participants feeling their knowledge and skills had been improved more than a control group. No other studies looking at repetition in simulation training could be found.
Experimental design and methods
The study will be a mainly quantitative methodology (with a qualitative element), using an experimental design. Trainees will be randomised (via sealed envelopes) to either the repetitive or single scenario simulation session. This will be followed, in both groups, by a new scenario which will videorecorded.
The 'new' scenario will be rated by 2 examiners familiar with Anaesthetic Non-Technical Skills assessment (who will be blinded). The interview, following the 'new' scenario will ask the trainees to rate aspects of the teaching session. The interview will then use a qualitative approach, through more open ended questions, attempting to elucidate the reasons for any observed quantitative effect and to establish the acceptability of repetitive scenarios. The post scenario interview will be recorded and the free text responses coded.
Developing a clinical measurement of depth of anaesthesia using brain connectivity measures
Dr David Smith
Background
Monitoring the adequacy of anaesthesia of patients undergoing surgery presents difficulties for anaesthetists. An adequate level of anaesthesia prevents pain, awareness and recall of prompt emergence from unconsciousness when required. At present clinical signs, such as heart rate, blood pressure, and sweating, are used to indicate adequate depth of anaesthesia in clinical practice. However, these parameters do not correlate well with the level of consciousness of a patient. There continue to be rare but well publicised cases of patients being conscious during surgical procedures, and there is increasing evidence that excessive levels of anaesthesia may cause harm. There is a real need for a reliable measure of adequacy of anaesthesia.
Rationale
Several attempts have been made to develop devices that process the response of the electrical signal from the brain in response to changing concentrations of anaesthetic drugs. Examples are the Bispectral index, Entropy, and the auditory evoked potential. The National Institute for Health and Clinical Excellence has recently recommended that these devices are potentially useful for anaesthetised patients, whilst acknowledging that further research is needed in this area. Anaesthetic drugs suppress the activity of the nerve cells in the brain, impairing their ability to process information and communicate with each other. This concept is the bias of the Entropy device. However, all the currently available devices are calibrated against changing blood concentrations of anaesthetic drugs, rather than against a measure of consciousness, and have not been evaluated during normal sleep.
A new approach to measure depth of anaesthesia that measures how different areas in the brain are connected has recently been proposed. One study has used this method to show that the connections in the brain alter during anaesthesia. However brain connectivity analysis has not been compared to established methods to estimate depth of anaesthesia.
Proposal: In this study we intend to compare existing methods to measure depth of anaesthesia (including the response of the brain to sound and the power of the brain signal) to the new method of brain connectivity. We will first carry out a study of 30 volunteers in our laboratory in order to evaluate different methods to measure brain connectivity of patients whilst they undergo anaesthesia. We will also measure the power of the brain signal and the response of the brain to sound using standard approaches. Thus will we be able to compare which of the approaches (the new ones or the old ones) best discriminate between when patients are conscious and when they are anesthetised.
An evaluation of the implementation and impact of a mentoring programme for Anaesthetists in the North East
Dr A Steven
Being a doctor is challenging, requiring ability to manage complex clinical dilemmas and work collaboratively with patients and teams, while maintaining high professional standards. The Francis inquiry1 highlighted appalling failings: such incidents often happen in unsupportive or punitive NHS cultures where doctors fear raising concerns, have little support and are discouraged from learning with, and from, colleagues. It is crucial to develop supportive cultures and maintain level and quality of work so provision is patient-centred, safe and effective.
Mentoring schemes are one way of helping doctors at all career stages to manage dilemmas, deal with difficulties, cope with transitions and achieve their full potential. Many studies outside health care have shown the benefits of mentoring. There is a growing evidence base around the value of mentoring for doctors. More research is needed to understand how mentoring works and the best ways to train mentors and organise mentoring schemes.
Aims:
This study aims to evaluate the implementation and impact of a training programme for mentors and mentoring scheme for doctors.
The study will identify:
- How the mentors use the skills they learn on the training programme, what helps or hinders them using the skills and how useful the skills are.
- In relation to the mentoring scheme the study will identify what helps or hinders the
functioning of the scheme, and the advantages or problems related to being involved.
This information will assist the further development of mentor training and mentoring schemes so that they can be improved and made more effective and efficient for all involved. The broader purpose is to encourage the development of safe, supportive learning cultures.
Methodology:
This study uses a tried and tested approach to evaluating complicated initiatives. Rather than only exploring what happens before and after mentoring, this approach finds out what worked, for whom and in what ways, thus taking circumstances into consideration.
A questionnaire will collect information about the mentor programme and scheme at the beginning of the study. This information will be used to identify mentors and mentees within a range of diverse situations to interview. Interviews gather detailed information and offer participants the chance to raise issues of importance to them but not covered in the questionnaire. The questionnaire will be adapted and used again at the end of the period (12 months) to gather further information about activity and impact.
Both sets of questionnaire data will be analysed for changes over the course of the scheme. The interview data will be examined to develop a detailed picture of barriers, benefits, impact and ways of improving the programme and scheme. Interview data will be compared to questionnaire data to look for discrepancies.
Expected outcomes
A detailed assessment of barriers, facilitators and perceived impact of the training programme and mentoring scheme. A series of practical recommendations.
Implications
The findings will result in practical recommendations for improving both training programme and mentoring scheme. Academic papers and presentations will be developed to add to current literature regarding mentoring.
Introduction of real-time, mandatory recording of quality indicator data in anaesthesia recovery and regular feedback using statistical process control: the effect on clinician
performance and engagement
Dr Stephen Wright
Background: Almost 50,000 patients undergo operations in the Newcastle Hospitals each year. Our pilot data would suggest that it is not uncommon for patients to have problems with severe pain, nausea and vomiting, or to be cold on waking from their operation. To address this, we have recently designed a novel computer-based system, with mandatory data entry, to collect data from every patient when they wake up from their anaesthetic. These results will be collected for each individual Consultant and fed-back to them at regular intervals. Their scores will be shown to them with the average for their colleagues as a comparison. While this may immediately appear a good thing there is actually little good quality evidence to prove that such systems work. It is also clear from other areas of heath care that not all doctors engage with and "buy-in" to such systems. We would like to investigate these issues with the aim of improving the care of patients undergoing anaesthesia.
Aims: This study aims to rigorously assess whether the introduction of a quality improvement initiative including routine data collection and regular feedback helps consultant anaesthetists improve the care of patients undergoing anaesthesia. We will objectively measure the engagement of consultants using a number of approaches including the validated Medical Engagement Scale (MES). We will assess whether the level of engagement predicts performance, as well as exploring clinician's perceptions of the initiative and their intention to change behaviour as a result.
Design: This study will run continuously for 21 months, with routine data collection being
incorporated into clinical practice. Baseline data will be collected for six months, before starting the feedback intervention. Questionnaires will be administered at baseline and at the end of the study.
Participants: One hundred consultant anaesthetists, 34 of whom have previously taken part in the pilot work in Leazes Recovery at the RVI.
Intervention: monthly, personalised, comparative feedback on locally-developed quality indicators will be given to participating consultants.
Outcomes: The primary outcomes will be the change in the proportion of patients experiencing the quality indicators, or how rapidly the trend is changing, before and after the intervention. The level of engagement at baseline will be assessed, along with other potential factors that may influence performance, such as consultant age, time in post, sub-speciality interest etc. Baseline engagement will be compared to that at the end of the study for each participant. The Three quality indicators are: (1) Proportion of patients with a body temperature < 36oC on arrival in anaesthesia recovery;
(2) Proportion of patients with severe pain in recovery (defined as either "pain score in recovery of 9 or 10 at any time" or "writhing or moaning in pain at any time"); (3) Proportion of patients with severe post-operative nausea and vomiting (defined as "PONV unresponsive to two anti-emetics in recovery"). Medical engagement with the organisation and the project will be measured using the Medical Engagement Scale, and a second "perception-behaviour" questionnaire incorporating questions developed previously by a co-applicant (JB) and up to 12 new questions assessing behaviour change.
