Gaba, David M.

Anesthesiologists are sometimes slow to adopt new technologies despite proven benefits. The authors undertook to understand community anesthesiologists’ perspectives and practices regarding neuromuscular monitoring and reversal. Specifically, they sought to generate evidence for why some guidance-congruent practices— i.e. , quantitative train-of-four monitoring, ulnar nerve stimulation, and evidence-based reversal—remain inconsistently adopted despite robust evidence of patient harm from residual neuromuscular blockade and decades of effort to improve adoption. Thirty-six U.S. community anesthesiologists underwent a detailed qualitative cognitive interview. Analysis revealed four clinician archetypes whose neuromuscular monitoring and reversal practices are shaped by identifiable individual and practice-related biases and device- and system-level barriers. Perceived confidence in sugammadex efficacy was frequently cited as a rationale for omitting quantitative neuromuscular monitoring. The authors propose a research and implementation action agenda to close the evidence-to-practice gap in neuromuscular monitoring and reversal.

Effective decision-making in crisis events is challenging due to time pressure, uncertainty, and dynamic decisional environments. We conducted a systematic literature review in PubMed and PsycINFO, identifying 32 empiric research papers that examine how trained professionals make naturalistic decisions under pressure. We used structured qualitative analysis methods to extract key themes. The studies explored different aspects of decision-making across multiple domains. The majority (19) focused on healthcare; military, fire and rescue, oil installation, and aviation domains were also represented. We found appreciable variability in research focus, methodology, and decision-making descriptions. We identified five main themes: (1) decision-making strategy, (2) time pressure, (3) stress, (4) uncertainty, and (5) errors. Recognition-primed decision-making (RPD) strategies were reported in all studies that analyzed this aspect. Analytical strategies were also prominent, appearing more frequently in contexts with less time pressure and explicit training to generate multiple explanations. Practitioner experience, time pressure, stress, and uncertainty were major influencing factors. Professionals must adapt to the time available, types of uncertainty, and individual skills when making decisions in high-risk situations. Improved understanding of these decisional factors can inform evidence-based enhancements to training, technology, and process design.

Abstract Introduction: Even physicians who routinely work in complex, dynamic practices may be unprepared to optimally manage challenging critical events. High-fidelity simulation can realistically mimic critical clinically relevant events, however the reliability and validity of simulation-based assessment scores for practicing physicians has not been established.Methods: Standardised complex simulation scenarios were developed and administered to board-certified, practicing anesthesiologists who volunteered to participate in an assessment study during formative maintenance of certification activities. A subset of the study population agreed to participate as the primary responder in a second scenario for this study. The physicians were assessed independently by trained raters on both teamwork/behavioural and technical performance measures. Analysis using Generalisability and Decision studies were completed for the two scenarios with two raters.Results: The behavioural score was not more reliable than the technical score. With two raters > 20 scenarios would be required to achieve a reliability estimate of 0.7. Increasing the number of raters for a given scenario would have little effect on reliability.Conclusions: The performance of practicing physicians on simulated critical events may be highly context-specific. Realistic simulation-based assessment for practicing physicians is resource-intensive and may be best-suited for individualized formative feedback. More importantly, aggregate data from a population of participants may have an even higher impact if used to identify skill or knowledge gaps to be addressed by training programs and inform continuing education improvements across the profession.

Abstract Introduction: Even physicians who routinely work in complex, dynamic practices may be unprepared to optimally manage challenging critical events. High-fidelity simulation can realistically mimic critical clinically relevant events, however the reliability and validity of simulation-based assessment scores for practicing physicians has not been established.Methods: Standardized complex simulation scenarios were developed and administered to board-certified, practicing anesthesiologists who volunteered to participate in an assessment study during formative maintenance of certification activities. A subset of the study population agreed to participate as the primary responder in a second scenario for this study. The physicians were assessed independently by trained raters on both teamwork/behavioral and technical performance measures. Analysis using Generalizability and Decision studies were completed for the two scenarios with two raters.Results: The technical score was not more reliable than the behavioral score. With two raters > 20 scenarios would be required to achieve a reliability estimate of 0.7. Increasing the number of raters would have little effect on reliability.Discussion: The performance of practicing physicians on simulated critical events may be highly context-specific. Realistic simulation-based assessment for practicing physicians is resource-intensive and may be best-suited for individualized formative feedback. Moreover, aggregate data from a population of participants may yield even higher impact if used to identify skill or knowledge gaps to be addressed by training programs and continuing education improvements across the profession.