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Anesthesiology 2005; 103:241– 8 © 2005 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Nontechnical Skills in Anesthesia Crisis Management with
Repeated Exposure to Simulation-based Education
Bevan Yee, M.B.Ch.B., F.A.N.Z.C.A.,* Viren N. Naik, M.D., M.Ed., F.R.C.P.C.,† Hwan S. Joo, M.D., F.R.C.P.C.,‡
Georges L. Savoldelli, M.D.,§ David Y. Chung, M.B.B.S., F.A.N.Z.C.A.,* Patricia L. Houston, M.D., M.Ed., F.R.C.P.C.,㛳
Bruce J. Karatzoglou, B.Sc., R.R.C.P.,# Stanley J. Hamstra, Ph.D.**

Background: Critical incident reporting and observational crisis management.1,2 Nontechnical skills are those that
studies have identified nontechnical skills that are vital to suc- do not relate to medical knowledge or technical proce-
cessful anesthesia crisis management. Examples of such skills
include task management, team working, situation awareness,
dures but instead encompass cognitive skills (e.g., deci-
and decision making. These skills are not necessarily acquired sion making, situation awareness) and interpersonal
through clinical experience and may need to be specifically skills (e.g., exchanging information, assertiveness).2
taught. This study uses a high-fidelity patient simulator to assess These qualities are not necessarily acquired by anesthe-
the effect of repeated exposure to simulated anesthesia crises sia trainees through routine clinical experience and may
on the nontechnical skills of anesthesia residents.
Methods: After institutional research board approval and in-
need to be specifically taught.3
formed consent, 20 anesthesia residents were recruited. Each Despite worldwide adoption of patient simulation in
resident was randomized to participate as the primary anesthe- anesthesiology, there remains a lack of valid and reliable
siologist in the management of three different simulated anes- simulation performance assessment tools.4 Although
thesia crises using a high-fidelity patient simulator. After each most of the literature has focused on assessment of
session, videotaped footage was used to facilitate debriefing of
their nontechnical skills. The videotapes were later reviewed by
knowledge and technical skills during anesthesia simu-
two expert blinded independent assessors who rated each res- lation, research on nontechnical skills has become a
ident’s nontechnical skills by using a previously validated and recent area of interest.2,5–7 A comprehensive and reliable
reliable marking system. nontechnical skills assessment tool called the Anaesthe-
Results: A significant improvement in the nontechnical skills tists’ Non-Technical Skills (ANTS) system has recently
of residents was demonstrated from their first to second ses-
sion and from their first to third session (both P < 0.005).
been developed.5
However from their second to third session, no significant The hierarchical ANTS scoring system consists at the
improvement was observed. Interrater reliability between as- highest level of four basic skill categories, namely task
sessors was modest (single rater intraclass correlation ⴝ 0.53). management, team working, situation awareness, and
Conclusion: A single exposure to anesthesia crises using a decision making. These skill categories are further di-
high-fidelity patient simulator can improve the nontechnical
skills of anesthesia residents. However, an additional simula-
vided up into 15 skill elements. Each element is an-
tion session may confer little or no additional benefit. chored for rating with examples of behaviors indicating
good and poor practice.
TRADITIONAL anesthesia teaching has placed signifi- Although studies have addressed the issue of perfor-
cant emphasis on knowledge acquisition and the master- mance improvement with repeated simulation expo-
ing of technical skills. However, critical incident report- sure, all of these have focused on knowledge and tech-
ing and observational studies, both in the clinical setting nical skills ability.8 –11 Debriefing inclusive of videotape
and on patient simulators, have identified nontechnical review was used between simulation sessions in two of
skills to be major determinants of successful anesthesia these studies.9,10
The purpose of this study was to prospectively inves-
tigate the effects of repeated simulation of anesthesia
This article is featured in “This Month in Anesthesiology.” crisis management and videotape-aided debriefing on
䉫 Please see this issue of ANESTHESIOLOGY, page 5A. the nontechnical skills ability of anesthesia residents
using the ANTS scoring system.

* Fellow, ‡ Assistant Professor, 㛳 Associate Professor, St. Michael’s Anesthesia
Research into Teaching (SMART) Simulation Group, St. Michael’s Hospital, and Materials and Methods
Department of Anesthesia, † Assistant Professor, § Fellow, SMART Simulation
Group, St. Michael’s Hospital, Department of Anesthesia, and Wilson Centre for Recruitment and Orientation Phases
Research in Education, # Patient Simulation Centre Coordinator, SMART Simula-
tion Group, St. Michael’s Hospital, ** Associate Professor, SMART Simulation After institutional research board (St. Michael’s Hospi-
Group, St. Michael’s Hospital, Wilson Centre for Research in Education, and tal, University of Toronto, Toronto, Ontario, Canada)
Department of Surgery, University of Toronto.
Received from the Patient Simulation Centre, St. Michael’s Hospital, University
approval, anesthesia residents in postgraduate years 2
of Toronto, Toronto, Ontario, Canada. Submitted for publication September 27, and 4 from within the University of Toronto training
2004. Accepted for publication April 6, 2005. Supported by a grant from the program were invited to participate as study subjects.
Canadian Anesthesiologists’ Society, as provided by the Canadian Anesthesia
Research Foundation, Toronto, Ontario, Canada. Informed consent was obtained. There were no exclu-
Address reprint requests to Dr. Naik: Department of Anesthesia, St. Michael’s sion criteria. Residents were free to decline to partici-
Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, Canada M5B
1W8. Address electronic mail to: naikv@smh.toronto.on.ca. Individual article re-
pate. In addition to informed consent, confidentiality
prints may be purchased through the Journal Web site, www.anesthesiology.org. agreements were signed to ensure that information per-

Anesthesiology, V 103, No 2, Aug 2005 241

abdn.uk/iprc/ants_papers. Quebec. Canada). all subjects received a inated.. available as a secondary anesthesi. Canada). The secondary ANTS scoring system. and anesthe. Subjects attended their simulator sessions in groups of Nine different anesthesia crisis scenarios were used.1. Immediately after the scenario. St. taining to the simulation scenarios would not be dissem. cheal tube. residents not involved in this study working through the scenarios used for this study.†† They then underwent 4 h of training using the according to a script. Although each subject participated in some capacity in ios. Although many of the behaviors that the ary anesthesiologist. massive fat embolism. Each session consisted of three different scenar. local anesthesia toxicity. For each scenario.5†† The assessors were not familiar anesthesiologist was previously instructed to be a semi. and another subject remained in only three of them. Accessed No- assessment of each videotape. which consisted of the Datex® anesthesia machine (Datex Corporation. subject observed the scenario in a passive role. involving another clude practice at crisis management during an actual three different scenarios. Aug 2005 . A graphical display of the pa- tient’s vital signs throughout was overlaid onto the vid. there was no ing occurred after each of the three scenarios. The surgeon and nurse roles were played Manual. A further month later. investigations.3 The critique of each performance focused was held for all subjects.5 and the User diagnoses). three different scenarios. and anesthesia and operative way in a burn victim. The subjects were kept in the same group for the jects then participated in hands-on familiarization with duration of the study. active participant (i. perform tasks only if instructed. three. videotape-assisted debriefing. and the passive observer. Assessment Phase eotaped footage. ANTS scores were com- vember 24. the primary anesthesiologist tion and ACRM principles were recruited and trained by was able to call for help at any time from the secondary the principal investigators to be assessors using the anesthesiologist in an adjacent room. The assessors were free to use the videotape rewind function at any time. one subject played the role of the all nine scenarios.e. Ontario. sessions. the or- nel and one of the two principal study investigators der in which subjects participated as the primary anes- functioned as perioperative personnel in each scenario thesiologist was rotated over the three simulation ses- in the scripted roles of surgeon and nurse. A mock anesthesia record sheet con. A month later. 2004. Subjects rotated through the three scenarios. each was the primary anesthesiologist primary anesthesiologist.. In addition. and taining most of this information was also provided. These three scenarios. These videotapes documented performances by primary investigator in the control room. taking sia crisis resource management (ACRM) principles1.242 YEE ET AL. with any of the subjects. directed the prescripted scenario from the control room The responses to predicted therapeutic interventions with help from a simulator technician. and the mock operating each scenario. After the †† Available at: http://www. severe intracranial hypertension. This pipeline oxygen failure. again with debriefing after Laurent.ac. specific mention of the ANTS scoring system itself. progress to date. and they were available to perform ANTS system to independently rate the videotaped per- tasks only if instructed. pated in their third simulation session. period. an orientation session principles. Sub. were also standardized as much as possible.3 turns at being the primary anesthesiologist. difficult air- tory. Two staff anesthesiologists with expertise in simula- During the simulation. concealed massive hemorrhage. Initial assessor training consisted of providing them and not offer crisis management advice or differential with the background ANTS literature2. arated in time by 1 month. malignant hyperthermia. the second- were discussed. Simulation center person. lation was videotaped. pared. repeated performance assessments. each sep- in an adjacent room. crisis evolution. During the second and third scenario. patient simulation. The third sions. V 103. This orientation session did not in. During an initial 1-h didactic predominantly on nontechnical skills. No 2. and use of the system was discussed. The entire simu. The scenarios used were selected from the institution’s Each scenario consisted of a verbal handover from a existing ACRM teaching program and included latex principal investigator to the primary anesthesiologist anaphylaxis. guided by ACRM training Before the simulation sessions. debriefing of the performance of a given sub- ject was not specifically targeted to areas of weakness Interventions Phase identified during previous sessions. formed the basis for the ologist if help was requested. their second simulation session. The scenario concluded either formance of residents managing simulated anesthesia with resolution of the crisis or at the discretion of the crises. Each scenario had a predefined principal investigator then left the operating room and sequence of when and how the crisis situation evolved. the group partici- room environment. blocked endotra- that provided pertinent information such as patient his. the same group was the Laerdal SimMan® simulator mannequin and monitors bought back to the simulation center to participate in (Laerdal Medical Canada Ltd. Although no Anesthesiology.shtml. Toronto. A debrief- ANTS system addresses were discussed.

1.0 SD between the The ANTS system is hierarchical and consists of the first and third simulator sessions. These element scores were also compared using repeated- gory and element levels. second.13 With 20 subjects using a two-tailed ␣ of 0. IL). This limitation in the ANTS has been previ- Category Element ously observed. No 2. of team. Anesthetists’ Non-Technical Skills System Rating Scale ter reliability was measured at both the category and element levels. effect sizes of greater than 1. Anesthetists’ Non-Technical Skills System Categories turning it into a seven-point scale. enhancing patient safety.e. 1. 2. and decision making (table 1). i. Interra- Table 2. The behaviors observed were rated at both the cate.12 At the conclusion of the interventions phase of the Task management Planning and preparing study. Therefore. They viewed and rated all videotapes indepen- Using authority and assertiveness Assessing capabilities dently and in random order. and 4.. feedback by the assessors suggested this for multiple secondary outcomes. four skill categories of task management. It could be used as a positive example for others. Results 3—Acceptable Performance was of a satisfactory standard Demographics but could be improved.0 SD are Reevaluating acceptable in assessing teaching interventions. Rating Label Description 4—Good Performance was of a consistently high standard. ferroni correction for four primary outcomes. with a two-tailed P value of less than 0. we had scores that diverged widely were further discussed. 3. was an even distribution of 10 second-year and 10 Anesthesiology.” whereas one of poor performance is “over. Twenty-seven subjects were approached to take part Considerable improvement is needed. Chicago. 20 subjects who formed the basis for this study. all study videotapes were forwarded to the asses- Prioritizing Providing and maintaining standards sors. Aug 2005 . Significant results were then analyzed using a performance is “allocates tasks to appropriate members Tukey post hoc analysis. the assessors were Identifying and utilizing resources blinded as to whether a subject was performing as the Team working Coordinating activities with team members primary anesthesiologist in their first. after a poor performance. Analyzing be they individual case plans or longer term scheduling global rating scales parametrically. Borrowing from the Balancing risks and selecting options psychological field. is defined as “skills for orga. Supporting others Situation awareness Gathering information Recognizing and understanding Statistical Analysis Anticipating Statistical analysis was performed using SigmaStat 2. A two-tailed P value nontechnical skills observed (table 2).03 Decision making Identifying options (SPSS Incorporated. The ANTS scoring system uses measures analysis of variance for parametric data and chi- a four-point scale to describe the performance of the square analysis for nonparametric data. thus evaluated using intraclass correlation over the range of data. 2. During the rating process.” continuous data has become convention in the educa- Each skill category is further divided up in to a number tional literature because it is more powerful than non- of skill elements (table 1).5. Each skill element then has a parametric analysis.05 was considered statistically significant training phase. an example of good comes. as issues. in the skill element of Bonferroni correction for four independent primary out- identifying and utilizing resources. Twenty subjects completed three scenarios 1—Poor Performance endangered or potentially as the primary anesthesiologist and had adequate video- endangered patient safety. Task scores given by the assessors for the four skill categories. 2—Marginal Performance indicated cause for concern. 94% power to detect an effect size of 1. During the initial of less than 0. The secondary outcome measures used were the ANTS loads team members with tasks. Significant results four-point scale did not provide enough scope to rate were then analyzed using a Tukey post hoc analysis.5.NONTECHNICAL SKILLS: REPEATED SIMULATION EXPOSURE 243 Table 1. or third Exchanging information session. when possible. there Not observed Skill could not be observed in this scenario. V 103. team working.05.5. These category scores were analyzed parametrically us- nizing resources and required activities to achieve goals. many of the observed skills. in this study.0125. For example.0125 was considered statistically significant. and Elements 3. after a Bon- formal attempt was made to calibrate the assessors. management. the scale was Interrater reliability for the two ANTS assessors was modified to include the utilization of half points. Serious taped footage available for subsequent analysis. The primary outcome measures used were the ANTS situation awareness. Of the remediation is required.” scores given by the assessors for the 15 skill elements. for example. ing repeated-measures analysis of variance.13 A two-tailed P value of less than number of different example behaviors for good and 0.

Anesthesiology.41 3.72 0. fourth-year residents.62 0. NS ⴝ not signif- icant. Comparisons between Second.and Fourth-year Residents Second-year Residents (n ⫽ 10) Fourth-year Residents (n ⫽ 10) P Value Male:female 9:1 6:4 — No. fig. No significant differences were making. No significant differences were seen in the Primary Outcome Measures: Category Scores mean category scores between their second and third The ANTS results from the first sessions are most sessions (all P ⫽ not significant.72 2.12 Situation awareness 3.49 Team working 2. A greater number of male subjects sions (all P ⬍ 0. The scores from the second ses- sion correspond to the additional skills acquired from Secondary Outcome Measures: Element Scores the previous session’s training. situation awareness.05 ⫾ 0.15 Decision making 2.05 ⫾ 0.53 0.15 ⫾ 0.55 0.21 Situation awareness 3.62 3. V 103. reflective of the demographics P ⬍ 0. These results represent the effect of of our anesthesia training program (table 3).85 ⫾ 0. of subjects with previous simulator experience 2 9 — First session (pretest) Task management 2.48 0. effect of the additional intervention of a further simula- existing skill levels in the residents before additional tion session with debriefing 1 month later.34 Team working 2.25 ⫾ 0.39 3.90 ⫾ 0.10 ⫾ 0.90 ⫾ 0.31 Third session Task management 2. for all 15 of the nontechnical skill session should correspond to the additional skills ob. 1).00 ⫾ 0.52 Decision making 2.67 2. Aug 2005 .50 0.20 ⫾ 0. 2–5).72 2.81 2. representing the representative of preintervention control scores. and third sessions (all P ⫽ not significant. 1.66 0.10 Team working 2.95 ⫾ 0. there was significant improvement in the mean seen in the mean element scores between their second scores of subjects between their first and second ses.44 3. Fig.55 ⫾ 0.17 Situation awareness 2. fig. as pre. training was assessed.52 Data are expressed as mean ⫾ 1 SD. elements.34 3.45 ⫾ 0.20 Second session Task management 2.15 ⫾ 0. 1).60 ⫾ 0.25 ⫾ 0.05. sessions (all P ⬍ 0.244 YEE ET AL.59 0.05) and their first and third sessions ment.10 ⫾ 0. figs.25 ⫾ 0.47 0.50 0. figs.35 3.85 ⫾ 0.60 0. 2–5). Effect of repeated exposure to pa- tient simulation on the four primary non- technical skill categories.65 ⫾ 0.24 3. team working. The scores from the third At the element level. Table 3.005. mean scores of subjects between their first and second For each of the four skill categories of task manage.25 ⫾ 0. and decision (all P ⬍ 0. the intervention of a single simulation session with de- briefing.15 Decision making 2.25 ⫾ 0.90 ⫾ 0.005) and their first and third sessions (all participated in the study. No 2.34 3. there were significant improvements in the tained from the second session’s training (table 3).59 0.00 ⫾ 0.

001). First. P ⬍ 0. interrater reliability was The results from our study suggest that a single simu- modest (single rater intraclass correlation ⫽ 0. across the four categories. Aug 2005 . P ⬍ lation session improves the nontechnical skills of resi- 0. Currently. No 2. but in the evaluation of nontechnical skills.001). some additional points should sessions tended toward higher scores for fourth-year be considered. before removing additional simulation ses- Mean category scores for the first. inter. Effect of repeated exposure to pa- tient simulation on the secondary task management elements.53. Second. Interrater Reliability teaching with debriefing has become widespread among At the category level.NONTECHNICAL SKILLS: REPEATED SIMULATION EXPOSURE 245 Fig. 3. strating the benefit of this type of simulation based class correlation ⫽ 0. across the 15 elements. many anesthesia residency training programs. second. 2. many centers conduct successive Fig. dents did not achieve the maximum score by the third session. Effect of repeated exposures to high-fidelity patient simulation on the secondary team working elements. NS ⴝ not significant. training sessions to achieve and maintain proficiency in eled on ACRM-type courses involving scenario-based ACRM.versus Fourth-year Residents However. level. Second. studies in simula- Discussion tion have not yet examined the optimal interval between Anesthesia education using patient simulation mod. Anesthesiology. This suggests opportunities exist for further improvement in these skills. Demon- rater reliability overall was acceptable (single rater intra. NS ⴝ not signifi- cant. and third sions from a curriculum.50. dents. because resi- this was not statistically significant (table 3). An additional simulation session 1 month later seems to confer little or no additional benefit. we did not observe a ceiling effect residents as compared with second-year residents. V 103. At the element education has been problematic.

In our study. 4. It is possible that the short interval between our recognizing that creating scenarios of equal complexity simulation sessions was inadequate to show ongoing is challenging. This modification from clinical practice was incor- must attempt to control for familiarity of the simulation porated so that the scenarios involving relatively passive environment. the secondary anesthesiologist was in- ments in nontechnical skills were due to repeated expo. to debriefing. Effect of repeated exposure to pa- tient simulation on the secondary situa- tion awareness elements. However. the ran- tions to this study. we cannot determine whether the improve. Therefore. The study design aimed to inves- Fig. No 2. Our study lacked a control group domization of scenarios should have minimized this po- without serial exposure to simulation and debriefing. Effect of repeated exposure to pa- tient simulation on the secondary deci- sion-making elements. structed to perform tasks only if instructed to. NS ⴝ not signifi- cant. and not to sure to a simulation environment. tential bias. Studies of skills improvement through simulation gist. V 103. or to assume the leadership role of the primary anesthesiolo- both. and less verbal primary anesthesiologists were not taken mance are not entirely attributed to greater experience over by secondary anesthesiologists of a more vocal and with the test modality. Fig. Hence. 5. advantaged more senior trainees with greater medical There were several design and methodologic limita. knowledge and clinical experience. formal commencement of the study.14 An attempt was made to control aggressive disposition. so that observed improvements in perfor. NS ⴝ not signif- icant. some of our scenarios may have improvement in nontechnical skills. Anesthesiology. using modules incorporat.246 YEE ET AL. Aug 2005 . ACRM training sessions over a period of years (typically for this by introducing an orientation session before one full-day course per year). cialties. difficult by investigators with expertise in simulation. ing more ACRM-related concepts and more complex Our scenarios were subjectively judged to be equally scenarios and involving more of the anesthesia subspe.

therefore arises in attempting to devise a performance tually cooperative environment.6 available at: http://www. Weller et al. al. This was tically significant difference in the mean category scores confirmed by the statistically significant improvement in between second. assessment tool. assessment of nontechnical skills. the results mean category and element scores from the first to the trend toward superior nontechnical skills performance second and from the first to the third sessions. practice. how a subject is rated in the the relation between technical and behavioral (nontech. he or she was adopted. treatment protocols or guidelines. refers to the extent to which a test reflects the concept gist.6. safety and quality by adhering to accepted principles of edge and procedural skills. most groups showed that the levels of technical ments may have been influenced by the subject’s medi- and behavioral performance tended to match. This study was not powered to demonstrate statistically However. also makes no distinction between required nontechni- represented the other outlier pattern.” Moreover. the element of provid- Anesthesia crisis management should ideally combine ing and maintaining standards is defined as “supporting cognitive and interpersonal skills with medical knowl. the interrater reliability was modest and acceptable. improved skills in the simulator would trans- late into improved ability in real clinical situations. in fourth-year residents. that exclu- The design of this study necessitated that subjects sively measures nontechnical skills ability. evidence anesthesiology. With regard to reliability. the ANTS performance assessment tool does significant differences between junior and senior resi. such as the ANTS system.5 In this study. It knowledge. V 103. Validity and reliability must be present before an eval- Although within each session each subject was the pri. the significance of this interde. element of using authority and assertiveness is influ- nical) performance and showed a general trend of cor.org. edge and expertise. skills. and mental pendence is somewhat variable. Gaba et al. The greater nontechnical ability of the interrater reliability.and fourth-year residents. but they also learned passively from their participation that is being tested. subjects participated as the primary anesthesiologist over The expectation was that repeated simulation. It is probable that subjects nontechnical skills ability in the simulator environment not only learned nontechnical skills from the scenario and and fulfils some aspects of validity. because it assumes that behavioral and team processes but a lack of collective these skills are completely generic and context free. A larger study may have allowed us to demon. some of the categories strate statistically significant differences in performance and elements are inherently linked to medical knowl- between the groups of residents. However. Ideally.. and greater clinical experience. This is not surprising. because almost all of the technical skills is greater than when assessing technical fourth-year residents had a single previous remote simu.6‡‡ examined checklists. and it is verified if the test results are in the other scenarios. Although their management strategy. anesthesia. In our study. tern of outliers were groups that worked poorly as a Some additional criticisms of the ANTS system have team and thus had low behavioral scores. that the evaluation of nontechnical skills in certain ele- mance.NONTECHNICAL SKILLS: REPEATED SIMULATION EXPOSURE 247 tigate an individual’s serial performance as a team leader knowledge using a simple global rating scale. codes of good dependent. Aug 2005 . Initial evaluative studies with the ANTS system involved in some capacity for all three of the scenarios and have suggested that it is a reliable and usable measure of took part in three debriefings. Difficulty rather than the overall team performance within a mu. but had good been raised in a recent review. such that a poor technical score resulted. for this is lacking because of difficulties in creating and Anesthesiology. However. For example.12 The ANTS system does technical scores that resulted from the individual efforts not differentiate between those nontechnical skills of only a few members. attend in groups of three during each simulation session. 7 also cal skills in a given clinical setting and the generic set of demonstrated good correlation between behavior and nontechnical skills. The two domains are inter. tion of improved nontechnical skills ability. assessors having limited familiarity with the ANTS tool. validating ACRM simulation training. This trend was seen in all cate. Although it is used predominantly for dents. uative tool. enced by the appropriateness of their diagnosis and relation. we acknowledge study looked more at team rather than individual perfor. following where possible.5 Construct validity debriefing in which they were the primary anesthesiolo.7 Although the ANTS authors found satisfactory lator experience. thus ‡‡ See Web site addendum to Gaba et al. becomes widely mary anesthesiologist in only one scenario. have limitations. they mentioned that it was not ide- senior residents may have occurred through a combina. such as the ANTS system. but with some outlying values. the three simulation sessions. ulation environment. Accessed November 24. A single group that had good needed for different scenarios. debriefing. despite the primary investigators and tion of an increased familiarity with ACRM and the sim. We attempted to control for the in keeping with expectation. previous studies have shown gories and elements and in all three of the simulation that the variability between raters when assessing non- sessions. 2004. and nontechnical skills teaching would result in demonstra- Although we were not able to demonstrate any statis. The results of this study effect of passive learning by rotating the order in which imply that the ANTS scoring system has construct validity. No 2. cal knowledge. One pat.

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