Academic Appointments

Administrative Appointments

  • Chair, Clinical Competence Committee, Department of Anesthesia (2011 - Present)

Honors & Awards

  • Dean's Honor Society, University of California, Santa Barbara (1983)
  • Member, Alpha Omega Alpha (1986)
  • Elected member, Association of University Anesthesiologists (2005)
  • Excellence in Clinical Simulation Training, Education and Research Practice Award, SimLEARN -- VA National Simulation Program (2017)

Boards, Advisory Committees, Professional Organizations

  • Member, Educational Track Subcommittee on Professional Issues, American Society of Anesthesiologists (2008 - 2016)
  • Member, Scientific Evaluation Committee, Anesthesia Patient Safety Foundation (2008 - Present)
  • Member, Professional Advisory Committee, Malignant Hyperthermia Association of the United States (2009 - Present)
  • Member, Editorial Board, Simulation in Healthcare (2011 - Present)
  • Member, Abstract Review Committee on Patient Safety and Practice Management, American Society of Anesthesiologists (2012 - 2016)
  • Chairperson, Scientific Evaluation Committee, Anesthesia Patient Safety Foundation (2013 - 2020)
  • Member, Committee on Occupational Health, American Society of Anesthesiologists (2014 - Present)

Professional Education

  • --, Stanford, Anesthesia (1991)
  • --, Cedars-Sinai, UCLA, Internship (1988)
  • MD, Chicago Medical School, Medicine (1987)
  • BA, UC Santa Barbara, Pharmacology (1983)

Current Research and Scholarly Interests

Our laboratory is active in the study of human performance of medical personnel. We are actively involved in teaching health care personnel the techniques of crisis resource management (CRM) using realistic simulation.

My research centers on the effects of sleepiness and fatigue in medical personnel. Data from our studies reveal resident physicians to be pathologically sleepy (as tested in the sleep laboratory) during normal working conditions as well as in the post on-call condition. If the same subjects are allowed to extend night time sleep by two hours for four consecutive days they return to normal states of alertness. We have evaluated the effects of sleep deprivation on clinical performance using a realistic simulator. We are currently measuring the sleep propensity and performance of health care personnel (nurses, residents and staff physicians).

2022-23 Courses

Graduate and Fellowship Programs

All Publications

  • Pilot study to correlate objective eye-tracking data with timed subjective task completion using five local anesthetic systemic toxicity cognitive aids. Regional anesthesia and pain medicine Joo, S. S., Mariano, E. R., Neal, J. M., Weinberg, G. L., Kou, A., Hunter, O. O., Harrison, T. K., Udani, A. D., Howard, S. K. 2021

    View details for DOI 10.1136/rapm-2021-102547

    View details for PubMedID 33837138

  • A tale of two surges: messaging app and public COVID-19 data summarize one anesthesiology practice's pandemic year in review. Canadian journal of anaesthesia = Journal canadien d'anesthesie Leng, J. C., Tirumalai, A. A., Kou, A., Brun, C., Coffman, C., Harrison, T. K., Howard, S. K., Shum, C., Hammons, A., Mariano, E. R. 2021

    View details for DOI 10.1007/s12630-021-02088-x

    View details for PubMedID 34405359

  • Clinical Uses and Impacts of Emergency Manuals During Perioperative Crises. Anesthesia and analgesia Goldhaber-Fiebert, S. N., Bereknyei Merrell, S., Agarwala, A. V., De La Cruz, M. M., Cooper, J. B., Howard, S. K., Asch, S. M., Gaba, D. M. 2020; 131 (6): 1815–26


    BACKGROUND: Performing key actions efficiently during crises can determine clinical outcomes, yet even expert clinicians omit key actions. Simulation-based studies of crises show that correct performance of key actions dramatically increases when emergency manuals (EMs) are used. Despite widespread dissemination of EMs, there is a need to understand in clinical contexts, when, how, and how often EMs are used and not used, along with perceived impacts.METHODS: We conducted interviews with the anesthesia professionals involved in perioperative crises, identified with criterion-based sampling, occurring between October 2014 and May 2016 at 2 large academic medical centers with a history of EM training and implementation. Our convergent, mixed-methods study of the interview data extracted quantitative counts and qualitative themes of EM use and nonuse during clinical crises.RESULTS: Interviews with 53 anesthesia professionals yielded 80 descriptions of applicable clinical crises, with varying durations and event types. Of 69 unique patients whose cases involved crises, the EM was used during 37 (54%; 95% confidence interval [CI], 41-66). Impacts on clinician team members included decreased stress for individual anesthesia professionals (95%), enabled teamwork (73%), and calmed atmosphere (46%). Impacts on delivery of patient care included specific action improvements, including catching errors of omission, for example, turning off anesthetic during cardiac arrest, only after EM use (59%); process improvements, for example, double-checking all actions were completed (41%); and impediments (0%). In 8% of crises, EM use was associated with potential distractions, although none were perceived to harm delivery of patient care. For 32 EM nonuses (46%; 95% CI, 34-59), participants self-identified errors of omission or delays in key actions (56%), all key actions performed (13%), and crisis too brief for EM to be used (31%).CONCLUSIONS: This study provides evidence that EMs in operating rooms are being used during many applicable crises and that clinicians perceive EM use to add value. The reported negative effects were minimal and potentially offset by positive effects.

    View details for DOI 10.1213/ANE.0000000000005012

    View details for PubMedID 33197160

  • An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology Mudumbai, S. C., Kim, T. E., Howard, S. K., Giori, N. J., Woolson, S. n., Ganaway, T. n., Kou, A. n., King, R. n., Mariano, E. R. 2020; 73 (3): 267

    View details for DOI 10.4097/kjae.2016.69.4.368.e1

    View details for PubMedID 32506897

  • Quality of Patient Education Materials on Safe Opioid Management in the Acute Perioperative Period: What Do Patients Find Online? PAIN MEDICINE Kumar, G., Jaremko, K. M., Kou, A., Howard, S. K., Harrison, T., Mariano, E. R. 2020; 21 (1): 171–75

    View details for DOI 10.1093/pm/pny296

    View details for Web of Science ID 000522867400021

  • A Multidisciplinary Perioperative Intervention to Improve Positive Airway Pressure Adherence in Patients With Obstructive Sleep Apnea: A Case Series. A&A practice Wong, J. K., Rodriguez, E. M., Wee-Tom, B., Lejano, M., Kushida, C. A., Howard, S. K., Memtsoudis, S. G., Mariano, E. R. 2019


    Positive airway pressure (PAP) adherence in patients with obstructive sleep apnea (OSA) remains low despite known benefits. The postoperative inpatient period may represent a unique opportunity to address technical issues and promote self-efficacy, 2 important factors determining adherence, which may result in patients' seeking outpatient sleep medicine follow-up. We report our experience in developing a perioperative multidisciplinary intervention of reintroducing PAP therapy to nonadherent OSA patients with the intent of motivating patients to return to their outpatient sleep medicine clinics.

    View details for DOI 10.1213/XAA.0000000000001165

    View details for PubMedID 31876561

  • A short, sustainable intervention to help reduce day of surgery smoking rates among patients undergoing elective surgery JOURNAL OF CLINICAL ANESTHESIA Coffman, C. R., Howard, S. K., Mariano, E. R., Kou, A., Pollard, J., Boselli, R., Kangas, S., Leng, J. 2019; 58: 35–36
  • Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center PAIN MEDICINE King, R., Mariano, E. R., Yajnik, M., Kou, A., Kim, T., Hunter, O. O., Howard, S. K., Mudumbai, S. C. 2019; 20 (11): 2256–62

    View details for DOI 10.1093/pm/pnz023

    View details for Web of Science ID 000504316200019

  • Quality of Patient Education Materials on Safe Opioid Management in the Acute Perioperative Period: What Do Patients Find Online? Pain medicine (Malden, Mass.) Kumar, G., Jaremko, K. M., Kou, A., Howard, S. K., Harrison, T. K., Mariano, E. R. 2019


    Objective: Guidelines on postoperative pain management recommend inclusion of patient and caregiver education on opioid safety. Patient education materials (PEMs) should be written at or below a sixth grade reading level. We designed this study to compare the readability of online PEMs related to postoperative opioid management produced by institutions with and without a regional anesthesiology and acute pain medicine (RAAPM) fellowship.Methods: With institutional review board exemption, we constructed our cohort of PEMs by searching RAAPM fellowship websites from North American academic medical centers and identified additional websites using structured Internet searches. Readability metrics were calculated from PEMs using the TextStat 0.4.1 textual analysis package for Python 2.7. The primary outcome was the Flesch-Kincaid Grade Level (FKGL), a score based on words per sentence and syllables per word. We also compared fellowship-based and nonfellowship PEMs on the presence or absence of specific content-related items.Results: PEMs from 15 fellowship and 23 nonfellowship institutions were included. The mean (SD) FKGL for PEMs was grade 7.84 (1.98) compared with the recommended sixth grade level (P<0.001) and was not different between groups. Less than half of online PEMs contained explicit discussion of opioid tapering or cessation. Disposal and overdose risk were addressed more often by nonfellowship PEMs.Conclusions: Available online PEMs related to opioid management are beyond the recommended reading level, but readability metrics for online PEMs do not differ between fellowship and nonfellowship groups. More than two-thirds of RAAPM fellowship programs in North America are lacking readable online PEMs on safe postoperative opioid management.

    View details for PubMedID 30657963

  • Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Wong, J. K., Kim, T., Mudumbai, S. C., Memtsoudis, S. G., Giori, N. J., Howard, S. K., Oka, R. K., King, R., Mariano, E. R. 2019; 477 (1): 177–90
  • Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center. Pain medicine (Malden, Mass.) King, R. n., Mariano, E. R., Yajnik, M. n., Kou, A. n., Kim, T. E., Hunter, O. O., Howard, S. K., Mudumbai, S. C. 2019


    The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types.With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact.Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved.For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

    View details for PubMedID 30856269

  • Peripheral nerve blocks are not associated with increased risk of perioperative peripheral nerve injury in a Veterans Affairs inpatient surgical population. Regional anesthesia and pain medicine Yajnik, M. n., Kou, A. n., Mudumbai, S. C., Walters, T. L., Howard, S. K., Edward Kim, T. n., Mariano, E. R. 2019; 44 (1): 81–85


    Perioperative peripheral nerve injury (PNI) is a known complication in patients undergoing surgery with or without regional anesthesia. The incidence of new PNI in a Veterans Affairs (VA) inpatient surgical population has not been previously described; therefore, the incidence, risk factors, and clinical course of new PNI in this cohort are unknown. We hypothesized that peripheral nerve blocks do not increase PNI incidence.We conducted a 5-year review of a Perioperative Surgical Home database including all consecutive surgical inpatients. The primary outcome was new PNI between groups that did or did not have peripheral nerve blockade. Potential confounders were first examined individually using logistic regression, and then included simultaneously together within a mixed-effects logistic regression model. Electronic records of patients with new PNI were reviewed for up to a year postoperatively.The incidence of new PNI was 1.2% (114/9558 cases); 30 of 3380 patients with nerve block experienced new PNI (0.9%) compared with 84 of 6178 non-block patients (1.4%; p=0.053). General anesthesia alone, younger age, and American Society of Anesthesiologists physical status <3 were associated with higher incidence of new PNI. Patients who received transversus abdominis plane blocks had increased odds for PNI (OR, 3.20, 95% CI 1.34 to 7.63), but these cases correlated with minimally invasive general and urologic surgery. One hundred PNI cases had 1-year follow-up: 82% resolved by 3 months and only one patient did not recover in a year.The incidence of new perioperative PNI for VA surgical inpatients is 1.2% and the use of peripheral nerve blocks is not an independent risk factor.

    View details for PubMedID 30640657

  • Peripheral nerve blocks are not associated with increased risk of perioperative peripheral nerve injury in a Veterans Affairs inpatient surgical population REGIONAL ANESTHESIA AND PAIN MEDICINE Yajnik, M., Kou, A., Mudumbai, S. C., Walters, T. L., Howard, S. K., Kim, E., Mariano, E. R. 2019; 44 (1): 81–85
  • A Pilot Project Using Eye-Tracking Technology to Design a Standardised Anaesthesia Workspace. Turkish journal of anaesthesiology and reanimation Hanhan, J., King, R., Harrison, T. K., Kou, A., Howard, S. K., Borg, L. K., Shum, C., Udani, A. D., Mariano, E. R. 2018; 46 (6): 411-415


    Maximising safe handoff procedures ensures patient safety. Anaesthesiology practices have primarily focused on developing better communication tools. However, these tools tend to ignore the physical layout of the anaesthesia workspace itself. Standardising the anaesthesia workspace has the potential to improve patient safety. The design process should incorporate end user feedback and objective data.This pilot project aims to design a standardised anaesthesia workspace using eye-tracking technology at a single university-affiliated Veterans Affairs hospital. Twelve practising anaesthesiologists observed a series of images representing five clinical scenarios. Each of these had a question prompting them to look for certain items commonly found in the anaesthesia workspace. Using eye-tracking technology, the gaze data of participants were recorded. These data were used to generate heat maps of the specific areas of interest in the workspace that received the most fixation counts.The laryngoscope and propofol had the highest percentages of gaze fixations on the left-hand side of the workstation, in closest proximity to the anaesthesiologist. Atropine, although the highest percentage of gaze fixations (33%) placed it on the right-hand side of the workstation, also had 25% of gaze fixations centred over the anaesthesia cart.Gaze fixation analyses showed that anaesthesiologists identified locations for the laryngoscope and propofol within easy reach and emergency medications further away. Because eye tracking can provide objective data to influence the design process, it may be useful when developing standardised anaesthesia workspace templates for individual practices.

    View details for DOI 10.5152/TJAR.2018.67934

    View details for PubMedID 30505602

    View details for PubMedCentralID PMC6223869

  • A Pilot Project Using Eye-Tracking Technology to Design a Standardised Anaesthesia Workspace TURKISH JOURNAL OF ANAESTHESIOLOGY AND REANIMATION Hanhan, J., King, R., Harrison, T., Kou, A., Howard, S. K., Borg, L. K., Shum, C., Udani, A. D., Mariano, E. R. 2018; 46 (6): 411–15
  • Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery. Patient education and counseling Yajnik, M., Hill, J. N., Hunter, O. O., Howard, S. K., Kim, T. E., Harrison, T. K., Mariano, E. R. 2018


    OBJECTIVE: Effects of patient education on perioperative analgesic utilization are not well defined. We designed a simple pain management educational card for total knee arthroplasty (TKA) patients and retrospectively reviewed clinical data before and after implementation to test the hypothesis that more informed patients will use less opioid.METHODS: With IRB approval, we analyzed clinical data collected perioperatively on all TKA patients one month before (PRE) and one month after (POST) card implementation. The card was designed using a modified Delphi method; the front explained all analgesic medications and the Defense and Veterans Pain Rating Scale was on the back. The primary outcome was total opioid dosage in morphine milligram equivalents (MME) for the first two postoperative days. Secondary outcomes included daily opioid usage, pain scores, ambulation distance, hospital length of stay and use of antiemetics.RESULTS: There were 20 patients in each group with no differences in baseline characteristics. Total two-day MME [median (10th-90th percentiles)] was 71 (32-285) for PRE and 38 (1-117) for POST (p=0.001). There were no other differences.CONCLUSION: Educating TKA patients in multimodal pain management using a simple tool decreases opioid usage.PRACTICE IMPLICATIONS: Empowering TKA patients with education can reduce opioid use perioperatively.

    View details for PubMedID 30219634

  • Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? Clinical orthopaedics and related research Wong, J. K., Kim, T. E., Mudumbai, S. C., Memtsoudis, S. G., Giori, N. J., Howard, S. K., Oka, R. K., King, R., Mariano, E. R. 2018


    BACKGROUND: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.QUESTIONS/PURPOSES: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?METHODS: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.RESULTS: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).CONCLUSIONS: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.LEVEL OF EVIDENCE: Level III, therapeutic study.

    View details for PubMedID 30179946

  • Use of an Emergency Manual During an Intraoperative Cardiac Arrest by an Interprofessional Team: A Positive-Exemplar Case Study of a New Patient Safety Tool JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Merrell, S., Gaba, D. M., Agarwala, A., Cooper, J. B., Nevedal, A. L., Asch, S. M., Howard, S. K., Goldhaber-Fiebert, S. N. 2018; 44 (8): 477–84


    An emergency manual (EM) is a set of evidence-based crisis checklists, or cognitive aids, that can improve team performance. EMs are used in other safety-critical industries, and health care simulation studies have shown their efficacy, but use in clinical settings is nascent. A case study was conducted on the use of an EM during one intraoperative crisis, which entailed the assessment of the impact of the EM's use on teamwork and patient care and the identification of lessons for effectively using EMs during future clinical crises.In a case study of a single crisis, an EM was used during a cardiac arrest at a tertiary care hospital that had systematically implemented perioperative EMs. Semistructured interviews were conducted with all six clinicians present, interview transcripts were iteratively coded, and thematic analysis was performed.All clinician participants stated that EM use enabled effective team functioning via reducing stress of individual clinicians, fostering a calm work environment, and improving teamwork and communication. These impacts in turn improved the delivery of patient care during a clinical crisis and influenced participants' intended EM use during future appropriate crises.In this positive-exemplar case study, an EM was used to improve delivery of evidence-based patient care through effective clinical team functioning. EM use must complement rather than replace good clinician education, judgment, and teamwork. More broadly, understanding why and how things go well via analyzing positive-exemplar case studies, as a converse of root cause analyses for negative events, can be used to identify effective applications of safety innovations.

    View details for PubMedID 30071967

  • Using eye tracking technology to compare the effectiveness of malignant hyperthermia cognitive aid design. Korean journal of anesthesiology King, R. n., Hanhan, J. n., Harrison, T. K., Kou, A. n., Howard, S. K., Borg, L. K., Shum, C. n., Udani, A. D., Mariano, E. R. 2018


    Malignant hyperthermia is a rare but potentially fatal complication of anesthesia, and several different cognitive aids designed to facilitate a timely and accurate response to this crisis currently exist. Eye tracking technology can measure voluntary and involuntary eye movements, gaze fixation within an area of interest, and speed of visual response and has been used to a limited extent in anesthesiology.With eye tracking technology, we compared the accessibility of five malignant hyperthermia cognitive aids by collecting gaze data from twelve volunteer participants. Recordings were reviewed and annotated to measure the time required for participants to locate objects on the cognitive aid to provide an answer; cumulative time to answer was the primary outcome.For the primary outcome, there were differences detected between cumulative time to answer survival curves (P < 0.001). Participants demonstrated the shortest cumulative time to answer when viewing the Society for Pediatric Anesthesia (SPA) cognitive aid compared to four other publicly available cognitive aids for malignant hyperthermia, and this outcome was not influenced by the anesthesiologists' years of experience.This is the first study to utilize eye tracking technology in a comparative evaluation of cognitive aid design, and our experience suggests that there may be additional applications of eye tracking technology in healthcare and medical education. Potentially advantageous design features of the SPA cognitive aid include a single page, linear layout, and simple typescript with minimal use of single color blocking.

    View details for PubMedID 29760370

  • Perioperative ACLS/Cognitive Aids in Resuscitation. International anesthesiology clinics Wen, L. Y., Howard, S. K. 2017; 55 (3): 4-18

    View details for DOI 10.1097/AIA.0000000000000150

    View details for PubMedID 28598877

  • Implementation of clinical practice changes by experienced anesthesiologists after simulation-based ultrasound-guided regional anesthesia training. Korean journal of anesthesiology Kim, T. E., Ganaway, T., Harrison, T. K., Howard, S. K., Shum, C., Kuo, A., Mariano, E. R. 2017; 70 (3): 318-326


    Anesthesiologists who have finished formal training and want to learn ultrasound-guided regional anesthesia (UGRA) commonly attend 1 day workshops. However, it is unclear whether participation actually changes clinical practice. We assessed change implementation after completion of a 1 day simulation-based UGRA workshop.Practicing anesthesiologists who participated in a 1 day UGRA course from January 2012 through May 2014 were surveyed. The course consisted of clinical observation of UGRA procedures, didactic lectures, ultrasound scanning, hands-on perineural catheter placement, and mannequin simulation. The primary outcome was the average number of UGRA blocks per month reported at follow-up versus baseline. Secondary outcomes included preference for ultrasound as the nerve localization technique, ratings of UGRA teaching methods, and obstacles to performing UGRA.Survey data from 46 course participants (60% response rate) were included for analysis. Participants were (median [10th-90th percentile]) 50 (37-63) years old, had been in practice for 17 (5-30) years, and were surveyed 27 (10-34) months after their UGRA training. Participants reported performing 24 (4-90) blocks per month at follow-up compared to 10 (2-24) blocks at baseline (P < 0.001). Compared to baseline, more participants at follow-up preferred ultrasound for nerve localization. The major obstacle to implementing UGRA in clinical practice was time pressure.Participation in a 1 day simulation-based UGRA course may increase UGRA procedural volume by practicing anesthesiologists.

    View details for DOI 10.4097/kjae.2017.70.3.318

    View details for PubMedID 28580083

    View details for PubMedCentralID PMC5453894

  • A matched case-control comparison of hospital costs and outcomes for knee replacement patients admitted postoperatively to acute care versus rehabilitation. Journal of anesthesia Tse, B. K., Walters, T. L., Howard, S. K., Kim, T. E., Memtsoudis, S. G., Sun, E. C., Kou, A., Graham, L., King, R., Mariano, E. R. 2017


    For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.

    View details for DOI 10.1007/s00540-017-2372-9

    View details for PubMedID 28477230

  • Randomized comparison of popliteal-sciatic perineural catheter tip migration and dislocation in a cadaver model using two catheter designs. Korean journal of anesthesiology Steffel, L., Howard, S. K., Borg, L., Mariano, E. R., Leng, J. C., Kim, T. E. 2017; 70 (1): 72-76


    New catheter-over-needle (CON) technology for continuous peripheral nerve blockade has emerged, but its effect on the risk of perineural catheter tip dislocation is unknown. Less flexible catheters may be more likely to migrate away from the nerve with simulated patient movement. In the present study, we evaluated catheter tip migration between CON catheters and traditional catheter-through-needle (CTN) catheters during ultrasound-guided short-axis in-plane (SAX-IP) insertion.We evaluated the migration of popliteal-sciatic catheters in a prone, unembalmed male cadaver. Thirty catheter placement trials were divided randomly into two groups based on the catheter type: CON or CTN. A single anesthesiology resident placed the catheters by SAX-IP insertion, and the catheters were then examined by ultrasound before and after ipsilateral knee range of motion (ROM) exercises (0°-130° flexion). A blinded expert regional anesthesiologist performed caliper measurements on the ultrasound images before and after the ROM exercises. The primary outcome was the change in distance from the catheter tip to the center of the nerve (cm) between before and after the ROM exercises.The change in the tip-to-nerve distance (median [10th-90th percentile]) was 0.06 (-0.16 to 0.23) cm for the CTN catheter and 0.00 (-0.12 to 0.69) for the CON catheter (P = 0.663). However, there was a statistically significant increase in dislocation out of the nerve compartment for the CON catheter (4/15; 0/15 for CTN) (P = 0.043).Although the use of different catheter designs had no effect on the change in the measured migration distance of popliteal-sciatic catheters, 27% of the CON catheters were dislocated out of the nerve compartment. These results may influence the choice of catheter design when using SAX-IP perineural catheter insertion.

    View details for DOI 10.4097/kjae.2017.70.1.72

    View details for PubMedID 28184270

  • Staging Evaluation and Response Criteria Harmonization (SEARCH) for Childhood, Adolescent and Young Adult Hodgkin Lymphoma (CAYAHL): Methodology statement. Pediatric blood & cancer Flerlage, J. E., Kelly, K. M., Beishuizen, A., Cho, S., De Alarcon, P. A., Dieckmann, U., Drachtman, R. A., Hoppe, B. S., Howard, S. C., Kaste, S. C., Kluge, R., Kurch, L., Landman-Parker, J., Lewis, J., Link, M. P., McCarten, K., Punnett, A., Stoevesandt, D., Voss, S. D., Wallace, W. H., Mauz-Körholz, C., Metzger, M. L. 2017


    International harmonization of staging evaluation and response criteria is needed for childhood, adolescence, and young adulthood Hodgkin lymphoma. Two Hodgkin lymphoma protocols from cooperative trials in Europe and North America were compared for areas in need of harmonization, and an evidence-based approach is currently underway to harmonize staging and response evaluations with a goal to enhance comparisons, expedite identification of effective therapies, and aid in the approval process for new agents by regulatory agencies.

    View details for DOI 10.1002/pbc.26421

    View details for PubMedID 28097818

  • Preliminary Experience Using Eye-Tracking Technology to Differentiate Novice and Expert Image Interpretation for Ultrasound-Guided Regional Anesthesia. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Borg, L. K., Harrison, T. K., Kou, A. n., Mariano, E. R., Udani, A. D., Kim, T. E., Shum, C. n., Howard, S. K. 2017


    Objective measures are needed to guide the novice's pathway to expertise. Within and outside medicine, eye tracking has been used for both training and assessment. We designed this study to test the hypothesis that eye tracking may differentiate novices from experts in static image interpretation for ultrasound (US)-guided regional anesthesia.We recruited novice anesthesiology residents and regional anesthesiology experts. Participants wore eye-tracking glasses, were shown 5 sonograms of US-guided regional anesthesia, and were asked a series of anatomy-based questions related to each image while their eye movements were recorded. The answer to each question was a location on the sonogram, defined as the area of interest (AOI). The primary outcome was the total gaze time in the AOI (seconds). Secondary outcomes were the total gaze time outside the AOI (seconds), total time to answer (seconds), and time to first fixation on the AOI (seconds).Five novices and 5 experts completed the study. Although the gaze time (mean ± SD) in the AOI was not different between groups (7 ± 4 seconds for novices and 7 ± 3 seconds for experts; P = .150), the gaze time outside the AOI was greater for novices (75 ± 18 versus 44 ± 4 seconds for experts; P = .005). The total time to answer and total time to first fixation in the AOI were both shorter for experts.Experts in US-guided regional anesthesia take less time to identify sonoanatomy and spend less unfocused time away from a target compared to novices. Eye tracking is a potentially useful tool to differentiate novices from experts in the domain of US image interpretation.

    View details for PubMedID 28777464

  • Comparative Echogenicity of an Epidural Catheter and 2 New Catheters Designed for Ultrasound-Guided Continuous Peripheral Nerve Blocks. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Moy, D. M., Kim, T. E., Harrison, T. K., Leng, J. C., Carvalho, B. n., Howard, S. K., Shum, C. n., Kou, A. n., Mariano, E. R. 2017


    Visualization of the catheter during ultrasound-guided continuous nerve block performance may be difficult but is an essential skill for regional anesthesiologists. The objective of this in vitro study was to evaluate 2 newer catheters designed for enhanced echogenicity and compare them to a widely used catheter not purposely designed for ultrasound guidance. Outcomes were the numbers of first-place rankings among all 3 catheters and scores on individual echogenicity criteria as assessed by 2 blinded reviewers. Catheters designed for echogenicity are not superior to an older regional anesthesia catheter, and results suggest that catheter preference for ultrasound-guided placement may be subjective.

    View details for PubMedID 28627724

  • Virtual reality distraction decreases routine intravenous sedation and procedure-related pain during preoperative adductor canal catheter insertion: a retrospective study. Korean journal of anesthesiology Pandya, P. G., Kim, T. E., Howard, S. K., Stary, E. n., Leng, J. C., Hunter, O. O., Mariano, E. R. 2017; 70 (4): 439–45


    Virtual reality (VR) distraction is a nonpharmacological method to prevent acute pain that has not yet been thoroughly explored for anesthesiology. We present our experience using VR distraction to decrease routine intravenous sedation for patients undergoing preoperative perineural catheter insertion.This 1-month quality improvement project involved all elective unilateral primary total knee arthroplasty patients who received a preoperative adductor canal catheter. Clinical data were analyzed retrospectively. For the first half of the month, all patients received usual care; intravenous sedation was administered at the discretion of the regional anesthesiologist. For the second half of the month, patients were offered VR distraction with intravenous sedation upon request. The primary outcome was fentanyl dosage; other outcomes included midazolam dosage, procedure-related pain, procedural time, and blood pressure changes.Seven patients received usual care and seven used VR. In the VR group, 1/7 received intravenous sedation versus 6/7 who received usual care (P = 0.029). The fentanyl dose was lower (median [10th-90th percentiles]) in the VR group (0 [0-20] µg) versus the non-VR group (50 [30-100] µg; P = 0.008). Midazolam use was lower in the VR group (0 [0-0] mg) than in the non-VR group (1 [0-1] mg; P = 0.024). Procedure-related pain was lower in the VR group (1 [1-4] NRS) versus the non-VR group (3 [2-6] NRS; P = 0.032). There was no difference in other outcomes.VR distraction may provide an effective nonpharmacological alternative to intravenous sedation for the ultrasound-guided placement of certain perineural catheters.

    View details for PubMedID 28794840

    View details for PubMedCentralID PMC5548947

  • The Perioperative Surgical Home model facilitates change implementation in anesthetic technique within a clinical pathway for total knee arthroplasty. Healthcare (Amsterdam, Netherlands) Mudumbai, S. C., Walters, T. L., Howard, S. K., Kim, T. E., Lochbaum, G. M., Memtsoudis, S. G., Kain, Z. N., Kou, A., King, R., Mariano, E. R. 2016; 4 (4): 334-339


    The challenge of knowledge translation in medical settings is well known, and implementing change in clinical practice can take years. For the increasing number total knee arthroplasty (TKA) patients annually, there is ample evidence to endorse neuraxial anesthesia over general anesthesia. The rate of adoption of this practice, however, is slow at the current time. We hypothesized that a Perioperative Surgical Home (PSH) model facilitates rapid change implementation in anesthesia.The PSH clinical pathways workgroup at a tertiary care Veterans Affairs hospital embarked on a 5-month process of changing the preferred anesthetic technique for patients undergoing TKA. This process involved multiple sequential steps: literature review; development of a work document; training of staff; and prospective collection of data. To assess the impact of this change, we examined data 6 months before (PRE, n=90) and after (POST) change implementation (n=128), and our primary outcome was the overall proportion of spinal anesthesia usage for each 6 month period. Secondary outcomes included minor and major complications associated with anesthetic technique.Over a period of one year, there was an increase in the proportion of patients who received spinal anesthesia (13% vs. 63%, p<0.001). For the following year, 53-92% of TKA patients per month received spinal anesthesia. There were no differences in major complications.Rapid and sustained change implementation in clinical anesthesia practice based on emerging evidence is feasible.Perioperative Surgical Home model may facilitate rapid change implementation in surgical care.Cohort study, Level 2.

    View details for DOI 10.1016/j.hjdsi.2016.03.002

    View details for PubMedID 28007227

  • A comparison of strength for two continuous peripheral nerve block catheter dressings. Korean journal of anesthesiology Borg, L., Howard, S. K., Kim, T. E., Steffel, L., Shum, C., Mariano, E. R. 2016; 69 (5): 506-509


    Despite the benefits of continuous peripheral nerve blocks, catheter dislodgment remains a major problem, especially in the ambulatory setting. However, catheter dressing techniques to prevent such dislodgment have not been studied rigorously. We designed this simulation study to test the strength of two commercially available catheter dressings.Using a cadaver model, we randomly assigned 20 trials to one of two dressing techniques applied to the lateral thigh: 1) clear adhesive dressing alone, or 2) clear adhesive dressing with an anchoring device. Using a digital luggage scale attached to a loop secured by the dressing, the same investigator applied steadily increasing force with a downward trajectory towards the floor until the dressing was removed or otherwise disrupted.The weight, measured (median [10th-90th percentile]) at the time of dressing disruption or removal, was 1.5 kg (1.3-1.8 kg) with no anchoring device versus 4.9 kg (3.7-6.5 kg) when the dressing included an anchoring device (P < 0.001).Based on this simulation study, using an anchoring device may help prevent perineural catheter dislodgement and therefore premature disruption of continuous nerve block analgesia.

    View details for PubMedID 27703632

  • Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study. Anesthesia and analgesia Goldhaber-Fiebert, S. N., Pollock, J., Howard, S. K., Bereknyei Merrell, S. 2016; 123 (3): 641-649


    Emergency manuals (EMs), context-relevant sets of cognitive aids or crisis checklists, have been used in high-hazard industries for decades, although this is a nascent field in health care. In the fall of 2012, Stanford clinically implemented EMs, including hanging physical copies in all Stanford operating rooms (ORs) and training OR clinicians on the use of, and rationale for, EMs. Although simulation studies have shown the effectiveness of EMs and similar tools when used by OR teams during crises, there are little data on clinical implementations and uses. In a subset of clinical users (ie, anesthesia residents), the objectives of this pilot study were to (1) assess perspectives on local OR safety culture regarding cognitive aid use before and after a systematic clinical implementation of EMs, although in the context of long-standing resident simulation trainings; and (2) to describe early clinical uses of EMs during critical events.Surveys collecting both quantitative and qualitative data were used to assess clinical adoption of EMs in the OR. A pre-implementation survey was e-mailed to Stanford anesthesia residents in mid-2011, followed by a post-implementation survey to a new cohort of residents in early 2014. The post-implementation survey included pre-implementation survey questions for exploratory comparison and additional questions for mixed-methods descriptive analyses regarding EM implementation, training, and clinical use during critical events since implementation.Response rates were similar for the pre- and post-implementation surveys, 52% and 57%, respectively. Comparing post- versus pre-implementation surveys in this pilot study, more residents: agreed or strongly agreed "the culture in the ORs where I work supports consulting a cognitive aid when appropriate" (73.8%, n = 31 vs 52.9%, n = 18, P = .0017) and chose more types of anesthesia professionals that "should use cognitive aids in some way," including fully trained anesthesiologists (z = -2.151, P = .0315). Fifteen months after clinical implementation of EMs, 19 respondents (45%) had used an EM during an actual critical event and 15 (78.9% of these) agreed or strongly agreed "the EM helped the team deliver better care to the patient" during that event, with the rest neutral. We present qualitative data for 16 of the 19 EM clinical use reports from free-text responses within the following domains: (1) triggering EM use, (2) reader role, (3) diagnosis and treatment, (4) patient care impact, and (5) barriers to EM use.Since Stanford's clinical implementation of EMs in 2012, many residents' self-report successful use of EMs during clinical critical events. Although these reports all come from a pilot study at a single institution, they serve as an early proof of concept for feasibility of clinical EM implementation and use. Larger, mixed-methods studies will be needed to better understand emerging facilitators and barriers and to determine generalizability.

    View details for DOI 10.1213/ANE.0000000000001445

    View details for PubMedID 27541721

  • Availability and Readability of Online Patient Education Materials Regarding Regional Anesthesia Techniques for Perioperative Pain Management. Pain medicine Kumar, G., Howard, S. K., Kou, A., Kim, T. E., Butwick, A. J., Mariano, E. R. 2016


    OBJECTIVE : Patient education materials (PEM) should be written at a sixth-grade reading level or lower. We evaluated the availability and readability of online PEM related to regional anesthesia and compared the readability and content of online PEM produced by fellowship and nonfellowship institutions. METHODS : With IRB exemption, we constructed a cohort of online regional anesthesia PEM by searching Websites from North American academic medical centers supporting a regional anesthesiology and acute pain medicine fellowships and used a standardized Internet search engine protocol to identify additional nonfellowship Websites with regional anesthesia PEM based on relevant keywords. Readability metrics were calculated from PEM using the TextStat 0.1.4 textual analysis package for Python 2.7 and compared between institutions with and without a fellowship program. The presence of specific descriptive PEM elements related to regional anesthesia was also compared between groups. RESULTS : PEM from 17 fellowship and 15 nonfellowship institutions were included in analyses. The mean (SD) Flesch-Kincaid Grade Level for PEM from the fellowship group was 13.8 (2.9) vs 10.8 (2.0) for the nonfellowship group (p = 0.002). We observed no other differences in readability metrics between fellowship and nonfellowship institutions. Fellowship-based PEM less commonly included descriptions of the following risks: local anesthetic systemic toxicity (p = 0.033) and injury due to an insensate extremity (p = 0.003). CONCLUSIONS : Available online PEM related to regional anesthesia are well above the recommended reading level. Further, fellowship-based PEM posted are at a higher reading level than PEM posted by nonfellowship institutions and are more likely to omit certain risk descriptions.

    View details for PubMedID 27485090

  • An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology Mudumbai, S. C., Kim, T. E., Howard, S. K., Giori, N. J., Woolson, S., Ganaway, T., Kou, A., King, R., Mariano, E. R. 2016; 69 (4): 368-375


    Both neuraxial and peripheral regional analgesic techniques offer postoperative analgesia for total hip arthroplasty (THA) patients. While no single technique is preferred, quadriceps muscle weakness from peripheral nerve blocks may impede rehabilitation. We designed this study to compare postoperative ambulation outcome in THA patients who were treated with a new ultrasound-guided fascia iliaca catheter (FIC) technique or intrathecal morphine (ITM).We reviewed the electronic health records of a sequential series of primary unilateral THA patients who were part of a standardized clinical pathway; apart from differences in regional analgesic technique, all other aspects of the pathway were the same. Our primary outcome was total ambulation distance (meters) combined for postoperative days 1 and 2. Secondary outcomes included daily opioid consumption (morphine milligram equivalents) and analgesic-related side effects. We examined the association between the primary outcome and analgesic technique by performing crude and adjusted ordinary least-squares linear regression. A P value < 0.05 was considered statistically-significant.The study analyzed the records of 179 patients (fascia iliaca, n = 106; intrathecal, n = 73). The primary outcome (total ambulation distance) did not differ between the groups (P = 0.08). Body mass index (BMI) was the only factor (β = -1.7 [95% CI -0.5 to -2.9], P < 0.01) associated with ambulation distance. Opioid consumption did not differ, while increased pruritus was seen in the intrathecal group (P < 0.01).BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not. An ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.

    View details for DOI 10.4097/kjae.2016.69.4.368

    View details for PubMedID 27482314

  • Feasibility of eye-tracking technology to quantify expertise in ultrasound-guided regional anesthesia JOURNAL OF ANESTHESIA Harrison, T. K., Kim, T. E., Kou, A., Shum, C., Mariano, E. R., Howard, S. K. 2016; 30 (3): 530-533


    Ultrasound-guided regional anesthesia (UGRA) requires an advanced procedural skill set that incorporates both sonographic knowledge of relevant anatomy as well as technical proficiency in needle manipulation in order to achieve a successful outcome. Understanding how to differentiate a novice from an expert in UGRA using a quantifiable tool may be useful for comparing educational interventions that could improve the rate at which one develops expertise. Exploring the gaze pattern of individuals performing a task has been used to evaluate expertise in many different disciplines, including medicine. However, the use of eye-tracking technology has not been previously applied to UGRA. The purpose of this preliminary study is to establish the feasibility of applying such technology as a measurement tool for comparing procedural expertise in UGRA. eye-tracking data were collected from one expert and one novice utilizing Tobii Glasses 2 while performing a simulated ultrasound-guided thoracic paravertebral block in a gel phantom model. Area of interest fixations were recorded and heat maps of gaze fixations were created. Results suggest a potential application of eye-tracking technology in the assessment of UGRA learning and performance.

    View details for DOI 10.1007/s00540-016-2157-6

    View details for Web of Science ID 000376675600027

    View details for PubMedID 26980475

  • Design and Implementation of a Perioperative Surgical Home at a Veterans Affairs Hospital. Seminars in cardiothoracic and vascular anesthesia Walters, T. L., Howard, S. K., Kou, A., Bertaccini, E. J., Harrison, T. K., Kim, T. E., Shafer, A., Brun, C., Funck, N., Siegel, L. C., Stary, E., Mariano, E. R. 2016; 20 (2): 133-140


    The innovative Perioperative Surgical Home model aims to optimize the outcomes of surgical patients by leveraging the expertise and leadership of physician anesthesiologists, but there is a paucity of practical examples to follow. Veterans Affairs health care, the largest integrated system in the United States, may be the ideal environment in which to explore this model. We present our experience implementing Perioperative Surgical Home at one tertiary care university-affiliated Veterans Affairs hospital. This process involved initiating consistent postoperative patient follow-up beyond the postanesthesia care unit, a focus on improving in-hospital acute pain management, creation of an accessible database to track outcomes, developing new clinical pathways, and recruiting additional staff. Today, our Perioperative Surgical Home facilitates communication between various services involved in the care of surgical patients, monitoring of patient outcomes, and continuous process improvement.

    View details for DOI 10.1177/1089253215607066

    View details for PubMedID 26392388

  • Comparative-Effectiveness of Simulation-Based Deliberate Practice Versus Self-Guided Practice on Resident Anesthesiologists' Acquisition of Ultrasound-Guided Regional Anesthesia Skills. Regional anesthesia and pain medicine Udani, A. D., Harrison, T. K., Mariano, E. R., Derby, R., Kan, J., Ganaway, T., Shum, C., Gaba, D. M., Tanaka, P., Kou, A., Howard, S. K. 2016; 41 (2): 151-157


    Simulation-based education strategies to teach regional anesthesia have been described, but their efficacy largely has been assumed. We designed this study to determine whether residents trained using the simulation-based strategy of deliberate practice show greater improvement of ultrasound-guided regional anesthesia (UGRA) skills than residents trained using self-guided practice in simulation.Anesthesiology residents new to UGRA were randomized to participate in either simulation-based deliberate practice (intervention) or self-guided practice (control). Participants were recorded and assessed while performing simulated peripheral nerve blocks at baseline, immediately after the experimental condition, and 3 months after enrollment. Subject performance was scored from video by 2 blinded reviewers using a composite tool. The amount of time each participant spent in deliberate or self-guided practice was recorded.Twenty-eight participants completed the study. Both groups showed within-group improvement from baseline scores immediately after the curriculum and 3 months following study enrollment. There was no difference between groups in changed composite scores immediately after the curriculum (P = 0.461) and 3 months following study enrollment (P = 0.927) from baseline. The average time in minutes that subjects spent in simulation practice was 6.8 minutes for the control group compared with 48.5 minutes for the intervention group (P < 0.001).In this comparative effectiveness study, there was no difference in acquisition and retention of skills in UGRA for novice residents taught by either simulation-based deliberate practice or self-guided practice. Both methods increased skill from baseline; however, self-guided practice required less time and faculty resources.

    View details for DOI 10.1097/AAP.0000000000000361

    View details for PubMedID 26866296

  • Can bedside patient-reported numbness predict postoperative ambulation ability for total knee arthroplasty patients with nerve block catheters? Korean journal of anesthesiology Mudumbai, S. C., Ganaway, T., Kim, T. E., Howard, S. K., Giori, N. J., Shum, C., Mariano, E. R. 2016; 69 (1): 32-36


    Adductor canal catheters offer advantages over femoral nerve catheters for knee replacement patients because they produce less quadriceps muscle weakness; however, applying adductor canal catheters in bedside clinical practice remains challenging. There is currently no patient-reported outcome that accurately predicts patients' physical function after knee replacement. The present study evaluates the validity of a relatively new patient-reported outcome, i.e., a numbness score obtained using a numeric rating scale, and assesses its predictive value on postoperative ambulation.We conducted a retrospective cohort study pooling data from two previously-published clinical trials using identical research methodologies. Both studies recruited patients undergoing knee replacement; one studied adductor canal catheters while the other studied femoral nerve catheters. Our primary outcome was patient-reported numbness scores on postoperative day 1. We also examined postoperative day 1 ambulation distance and its association with postoperative numbness using linear regression, adjusting for age, body mass index, and physical status.Data from 94 subjects were included (femoral subjects, n = 46; adductor canal subjects, n = 48). Adductor canal patients reported decreased numbness (median [10(th)-90(th) percentiles]) compared to femoral patients (0 [0-5] vs. 4 [0-10], P = 0.001). Adductor canal patients also ambulated seven times further on postoperative day 1 relative to femoral patients. There was a significant association between postoperative day 1 total ambulation distance and numbness (Beta = -2.6; 95% CI: -4.5, -0.8, P = 0.01) with R(2) = 0.1.Adductor canal catheters facilitate improved early ambulation and produce less patient-reported numbness after knee replacement, but the correlation between these two variables is weak.

    View details for DOI 10.4097/kjae.2016.69.1.32

    View details for PubMedID 26885299

  • Comparative Effectiveness of Two Ultrasound-Guided Regional Block Techniques for Surgical Anesthesia in Open Unilateral Inguinal Hernia Repair JOURNAL OF ULTRASOUND IN MEDICINE Steffel, L., Kim, T. E., Howard, S. K., Ly, D. P., Kou, A., King, R., Mariano, E. R. 2016; 35 (1): 177-182


    Transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (II/IH) nerve blocks have been described as analgesic adjuncts for inguinal hernia repair, but the efficacy of these techniques in providing intraoperative anesthesia, either individually or together, is not known. We designed this retrospective cohort study to test the hypothesis that combining TAP and II/IH nerve blocks ("double TAP" technique) results in greater accordance between the preoperative anesthetic plan and actual anesthetic technique provided when compared to TAP alone. Based on this study, double TAP may be preferred for patients undergoing open inguinal hernia repair who wish to avoid general anesthesia.

    View details for DOI 10.7863/ultra.15.02057

    View details for Web of Science ID 000367228500021

  • Improving Mastery Learning With Comparative Effectiveness. Academic medicine : journal of the Association of American Medical Colleges Udani, A. D., Mariano, E. R., Howard, S. K. 2016; 91 (6): 752

    View details for PubMedID 27218903

  • Comparative Effectiveness of Two Ultrasound-Guided Regional Block Techniques for Surgical Anesthesia in Open Unilateral Inguinal Hernia Repair. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Steffel, L., Kim, T. E., Howard, S. K., Ly, D. P., Kou, A., King, R., Mariano, E. R. 2015


    Transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (II/IH) nerve blocks have been described as analgesic adjuncts for inguinal hernia repair, but the efficacy of these techniques in providing intraoperative anesthesia, either individually or together, is not known. We designed this retrospective cohort study to test the hypothesis that combining TAP and II/IH nerve blocks ("double TAP" technique) results in greater accordance between the preoperative anesthetic plan and actual anesthetic technique provided when compared to TAP alone. Based on this study, double TAP may be preferred for patients undergoing open inguinal hernia repair who wish to avoid general anesthesia.

    View details for DOI 10.7863/ultra.15.02057

    View details for PubMedID 26614794

  • Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills. Journal of ultrasound in medicine Mariano, E. R., Harrison, T. K., Kim, T. E., Kan, J., Shum, C., Gaba, D. M., Ganaway, T., Kou, A., Udani, A. D., Howard, S. K. 2015; 34 (10): 1883-1893


    Practicing anesthesiologists have generally not received formal training in ultrasound-guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population.Anesthesiologists in practice for 10 years or more were recruited and enrolled to participate in a 1-day program: lectures and live-model ultrasound scanning (morning) and faculty-led iterative practice and mannequin-based simulation (afternoon). Participants were assessed and recorded while performing ultrasound-guided perineural catheter insertion at baseline, at midday (interval), and after the program (final). Videos were scored by 2 blinded reviewers using a composite tool and global rating scale. Participants were surveyed every 3 months for 1 year to report the number of procedures, efficacy of teaching methods, and implementation obstacles.Thirty-two participants were enrolled and completed the program; 31 of 32 (97%) completed the 1-year follow-up. Final scores [median (10th-90th percentiles)] were 21.5 (14.5-28.0) of 30 points compared to 14.0 (9.0-20.0) at interval (P < .001 versus final) and 12.0 (8.5-17.5) at baseline (P < .001 versus final), with no difference between interval and baseline. The global rating scale showed an identical pattern. Twelve of 26 participants without previous experience performed at least 1 perineural catheter insertion after training (P < .001). However, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline.Practicing anesthesiologists without previous training in ultrasound-guided regional anesthesia can acquire perineural catheter insertion skills after a 1-day standardized course, but changing clinical practice remains a challenge.

    View details for DOI 10.7863/ultra.14.12035

    View details for PubMedID 26384608

  • Simulation as a New Tool to Establish Benchmark Outcome Measures in Obstetrics PLOS ONE Kurrek, M. M., Morgan, P., Howard, S., Kranke, P., Calhoun, A., Hui, J., Kiss, A. 2015; 10 (6)


    There are not enough clinical data from rare critical events to calculate statistics to decide if the management of actual events might be below what could reasonably be expected (i.e. was an outlier).In this project we used simulation to describe the distribution of management times as an approach to decide if the management of a simulated obstetrical crisis scenario could be considered an outlier.Twelve obstetrical teams managed 4 scenarios that were previously developed. Relevant outcome variables were defined by expert consensus. The distribution of the response times from the teams who performed the respective intervention was graphically displayed and median and quartiles calculated using rank order statistics.Only 7 of the 12 teams performed chest compressions during the arrest following the 'cannot intubate/cannot ventilate' scenario. All other outcome measures were performed by at least 11 of the 12 teams. Calculation of medians and quartiles with 95% CI was possible for all outcomes. Confidence intervals, given the small sample size, were large.We demonstrated the use of simulation to calculate quantiles for management times of critical event. This approach could assist in deciding if a given performance could be considered normal and also point to aspects of care that seem to pose particular challenges as evidenced by a large number of teams not performing the expected maneuver. However sufficiently large sample sizes (i.e. from a national data base) will be required to calculate acceptable confidence intervals and to establish actual tolerance limits.

    View details for DOI 10.1371/journal.pone.0131064

    View details for Web of Science ID 000356932500138

    View details for PubMedID 26107661

    View details for PubMedCentralID PMC4480859

  • Comparison of catheter tip migration using flexible and stimulating catheters inserted into the adductor canal in a cadaver model. Journal of anesthesia Webb, C. A., Kim, T. E., Funck, N., Howard, S. K., Harrison, T. K., Ganaway, T., Keng, H., Mariano, E. R. 2015; 29 (3): 471-474


    Use of adductor canal blocks and catheters for perioperative pain management following total knee arthroplasty is becoming increasingly common. However, the optimal equipment, timing of catheter insertion, and catheter dislodgement rate remain unknown. A previous study has suggested, but not proven, that non-tunneled stimulating catheters may be at increased risk for catheter migration and dislodgement after knee manipulation. We designed this follow-up study to directly compare tip migration of two catheter types after knee range of motion exercises. In a male unembalmed human cadaver, 30 catheter insertion trials were randomly assigned to one of two catheter types: flexible or stimulating. All catheters were inserted using an ultrasound-guided short-axis in-plane technique. Intraoperative knee manipulation similar to that performed during surgery was simulated by five sequential range of motion exercises. A blinded regional anesthesiologist performed caliper measurements on the ultrasound images before and after exercise. Changes in catheter tip to nerve distance (p = 0.547) and catheter length within the adductor canal (p = 0.498) were not different between groups. Therefore, catheter type may not affect the risk of catheter tip migration when placed prior to knee arthroplasty.

    View details for DOI 10.1007/s00540-014-1957-9

    View details for PubMedID 25510467

  • A retrospective comparative provider workload analysis for femoral nerve and adductor canal catheters following knee arthroplasty JOURNAL OF ANESTHESIA Rasmussen, M., Kim, E., Kim, T. E., Howard, S. K., Mudumbai, S., Giori, N. J., Woolson, S., Ganaway, T., Mariano, E. R. 2015; 29 (2): 303-307


    Adductor canal catheters preserve quadriceps strength better than femoral nerve catheters and may facilitate postoperative ambulation following total knee arthroplasty. However, the effect of this newer technique on provider workload, if any, is unknown. We conducted a retrospective provider workload analysis comparing these two catheter techniques; all other aspects of the clinical pathway remained the same. The primary outcome was number of interventions recorded per patient postoperatively. Secondary outcomes included infusion duration, ambulation distance, opioid consumption, and hospital length of stay. Adductor canal patients required a median (10-90th percentiles) of 0.0 (0.0-2.6) interventions compared to 1.0 (0.3-3.0) interventions for femoral patients (p < 0.001); 18/23 adductor canal patients (78 %) compared to 2/22 femoral patients (9 %) required no interventions (p < 0.001). Adductor canal catheter infusions lasted 2.0 (1.4-2.0) days compared to 1.5 (1.0-2.7) days in the femoral group (p = 0.016). Adductor canal patients ambulated further [mean (SD)] than femoral patients on postoperative day 1 [24.5 (21.7) vs. 11.9 (14.6) meters, respectively; p = 0.030] and day 2 [44.9 (26.3) vs. 22.0 (22.2) meters, respectively; p = 0.003]. Postoperative opioid consumption and length of stay were similar between groups. We conclude that adductor canal catheters offer both patient and provider benefits when compared to femoral nerve catheters.

    View details for DOI 10.1007/s00540-014-1910-y

    View details for Web of Science ID 000352859100025

    View details for PubMedID 25217117

  • A pilot study to assess adductor canal catheter tip migration in a cadaver model JOURNAL OF ANESTHESIA Leng, J. C., Harrison, T. K., Miller, B., Howard, S. K., Conroy, M., Udani, A., Shum, C., Mariano, E. R. 2015; 29 (2): 308-312


    An adductor canal catheter may facilitate early ambulation after total knee arthroplasty, but there is concern over preoperative placement since intraoperative migration of catheters may occur from surgical manipulation and result in ineffective analgesia. We hypothesized that catheter type and subcutaneous tunneling may influence tip migration for preoperatively inserted adductor canal catheters. In a male unembalmed human cadaver, 20 catheter insertion trials were divided randomly into one of four groups: flexible epidural catheter either tunneled or not tunneled; or rigid stimulating catheter either tunneled or not tunneled. Intraoperative patient manipulation was simulated by five range-of-motion exercises of the knee. Distance and length measurements were performed by a blinded regional anesthesiologist. Changes in catheter tip to nerve distance (p = 0.225) and length of catheter within the adductor canal (p = 0.467) were not different between the four groups. Two of five non-tunneled stimulating catheters (40 %) were dislodged compared to 0/5 in all other groups (p = 0.187). A cadaver model may be useful for assessing migration of regional anesthesia catheters; catheter type and subcutaneous tunneling may not affect migration of adductor canal catheters based on this preliminary study. However, future studies involving a larger sample size, actual patients, and other catheter types are warranted.

    View details for DOI 10.1007/s00540-014-1922-7

    View details for Web of Science ID 000352859100026

    View details for PubMedID 25288506

  • Comparative Effectiveness of Infraclavicular and Supraclavicular Perineural Catheters for Ultrasound-Guided Through-the-Catheter Bolus Anesthesia. Journal of ultrasound in medicine Harrison, T. K., Kim, T. E., Howard, S. K., Funck, N., Wagner, M. J., Walters, T. L., Curtin, C., Chang, J., Ganaway, T., Mariano, E. R. 2015; 34 (2): 333-340


    Using a through-the-needle local anesthetic bolus technique, ultrasound-guided infraclavicular perineural catheters have been shown to provide greater analgesia compared to supraclavicular catheters. A through-the-catheter bolus technique, which arguably "tests" the anesthetic efficacy of the catheter before initiating an infusion, has been validated for infraclavicular catheters but not supraclavicular catheters. This study investigated the through-the-catheter bolus technique for supraclavicular catheters and tested the hypothesis that infraclavicular catheters provide faster onset of brachial plexus anesthesia.Preoperatively, patients were randomly assigned to receive either a supraclavicular or an infraclavicular catheter using an ultrasound-guided nonstimulating catheter insertion technique with a mepivacaine bolus via the catheter and ropivacaine perineural infusion initiated postoperatively. The primary outcome was time to achieve complete sensory anesthesia in the ulnar and median nerve distributions. Secondary outcomes included procedural time, procedure-related pain and complications, and postoperative pain, opioid consumption, sleep disturbances, and motor weakness.Fifty patients were enrolled in the study; all but 2 perineural catheters were successfully placed per protocol. Twenty-one of 24 (88%) and 24 of 24 (100%) patients in the supraclavicular and infraclavicular groups, respectively, achieved complete sensory anesthesia by 30 minutes (P= .088). There was no difference in the time to achieve complete sensory anesthesia. Supraclavicular patients reported more sleep disturbances postoperatively, but there were no statistically significant differences in other outcomes.Both supraclavicular and infraclavicular perineural catheters using a through-the-catheter bolus technique provide effective brachial plexus anesthesia.

    View details for DOI 10.7863/ultra.34.2.333

    View details for PubMedID 25614407

  • Simulation in teaching regional anesthesia: current perspectives. Local and regional anesthesia Udani, A. D., Kim, T. E., Howard, S. K., Mariano, E. R. 2015; 8: 33-43


    The emerging subspecialty of regional anesthesiology and acute pain medicine represents an opportunity to evaluate critically the current methods of teaching regional anesthesia techniques and the practice of acute pain medicine. To date, there have been a wide variety of simulation applications in this field, and efficacy has largely been assumed. However, a thorough review of the literature reveals that effective teaching strategies, including simulation, in regional anesthesiology and acute pain medicine are not established completely yet. Future research should be directed toward comparative-effectiveness of simulation versus other accepted teaching methods, exploring the combination of procedural training with realistic clinical scenarios, and the application of simulation-based teaching curricula to a wider range of learner, from the student to the practicing physician.

    View details for DOI 10.2147/LRA.S68223

    View details for PubMedID 26316812

  • A randomized comparison of long-axis and short-axis imaging for in-plane ultrasound-guided popliteal-sciatic perineural catheter insertion JOURNAL OF ANESTHESIA Kim, T. E., Howard, S. K., Funck, N., Harrison, T. K., Walters, T. L., Wagner, M. J., Ganaway, T., Mullens, J., Lehnert, B., Mariano, E. R. 2014; 28 (6): 854-860


    Ultrasound-guided long-axis in-plane sciatic perineural catheter insertion has been described but not validated. For the popliteal-sciatic nerve, we hypothesized that a long-axis in-plane technique, placing the catheter parallel and posterior to the nerve, results in faster onset of sensory anesthesia compared to a short-axis in-plane technique.Preoperatively, patients receiving a popliteal-sciatic perineural catheter were randomly assigned to either the long-axis or short-axis technique. Mepivacaine 2 % was administered via the catheter following insertion. The primary outcome was time to achieve complete sensory anesthesia. Secondary outcomes included procedural time, onset time of motor block, and pain on postoperative day 1.Fifty patients were enrolled. In the long-axis group (n = 25), all patients except 1 (4 %) had successful catheter placement per protocol. Two patients (8 %) in the long-axis group and 1 patient (4 %) in the short-axis group (n = 25) did not achieve sensory anesthesia by 30 min and were withdrawn. Seventeen of 24 (71 %) and 17 of 22 (77 %) patients in the short-axis and long-axis groups, respectively, achieved the primary outcome of complete sensory anesthesia (p = 0.589). The short-axis group (n = 17) required a median (10th-90th ‰) of 18.0 (8.4-30.0) min compared to 18.0 (11.4-27.6) min for the long-axis group (n = 17, p = 0.208) to achieve complete sensory anesthesia. Procedural time was 6.5 (4.0-12.0) min for the short-axis and 9.5 (7.0-12.7) min for the long-axis (p < 0.001) group. There were no statistically significant differences in other secondary outcomes.Long-axis in-plane popliteal-sciatic perineural catheter insertion requires more time to perform compared to a short-axis in-plane technique without demonstrating any advantages.

    View details for DOI 10.1007/s00540-014-1832-8

    View details for PubMedID 24789659

  • Value of expert systems, quick reference guides and other cognitive aids. Current opinion in anaesthesiology Wen, L. Y., Howard, S. K. 2014; 27 (6): 643-8


    Cognitive aids and other methods of decision support are receiving increased interest by the anesthesia community. These tools have significant safety implications because of the possibility to decrease variability in human performance.Studies of the use of cognitive aids during realistic simulations supports use of cognitive aids and other decision support tools.The early work in this field of decision support is encouraging but there are many questions regarding the optimal design, presentation and use.

    View details for DOI 10.1097/ACO.0000000000000130

    View details for PubMedID 25254573

  • Value of expert systems, quick reference guides and other cognitive aids CURRENT OPINION IN ANESTHESIOLOGY Wen, L. Y., Howard, S. K. 2014; 27 (6): 643-648
  • A Pilot In Vitro Evaluation of the "Air Test" for Perineural Catheter Tip Localization by a Novice Regional Anesthesiologist JOURNAL OF ULTRASOUND IN MEDICINE Johns, J., Harrison, T. K., Steffel, L., Howard, S. K., Kim, T. E., Kou, A., Mariano, E. R. 2014; 33 (12): 2197-2200


    The "air test" is used clinically to infer perineural catheter location and has been recently evaluated for use by experts. However, its utility for practitioners with less experience is unknown. We tested the hypothesis that the air test, when performed by a novice regional anesthesiologist, will improve assessment of perineural catheter tip position in a validated porcine-bovine model and determined the test's positive and negative predictive values, sensitivity, and specificity for a novice. In contrast to the results of the expert study, the air test did not improve the novice's assessment of perineural catheter tip location over chance.

    View details for DOI 10.7863/ultra.33.12.2197

    View details for Web of Science ID 000346232600019

    View details for PubMedID 25425379

  • A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty. Journal of ultrasound in medicine Mariano, E. R., Kim, T. E., Wagner, M. J., Funck, N., Harrison, T. K., Walters, T., Giori, N., Woolson, S., Ganaway, T., Howard, S. K. 2014; 33 (9): 1653-1662


    Proximal and distal (mid-thigh) ultrasound-guided continuous adductor canal block techniques have been described but not yet compared, and infusion benefits or side effects may be determined by catheter location. We hypothesized that proximal placement will result in faster onset of saphenous nerve anesthesia, without additional motor block, compared to a distal technique.Preoperatively, patients receiving an ultrasound-guided nonstimulating adductor canal catheter for knee arthroplasty were randomly assigned to either proximal or distal insertion. A local anesthetic bolus was administered via the catheter after successful placement. The primary outcome was the time to achieve complete sensory anesthesia in the saphenous nerve distribution. Secondary outcomes included procedural time, procedure-related pain and complications, postoperative pain, opioid consumption, and motor weakness.Proximal insertion (n = 23) took a median (10th-90th percentiles) of 12.0 (3.0-21.0) minutes versus 6.0 (3.0-21.0) minutes for distal insertion (n = 21; P= .106) to anesthetize the medial calf. Only 10 of 25 (40%) and 10 of 24 (42%) patients in the proximal and distal groups, respectively, developed anesthesia at both the medial calf and top of the patella (P= .978). Bolus-induced motor weakness occurred in 19 of 25 (76%) and 16 of 24 (67%) patients in the proximal and distal groups (P = .529). Ten of 24 patients (42%) in the distal group required intravenous morphine postoperatively, compared to 2 of 24 (8%) in the proximal group (P = .008), but there were no differences in other secondary outcomes.Continuous adductor canal blocks can be performed reliably at both proximal and distal locations. The proximal approach may offer minor analgesic and logistic advantages without an increase in motor block.

    View details for DOI 10.7863/ultra.33.9.1653

    View details for PubMedID 25154949

  • In response. Anesthesia and analgesia Goldhaber-Fiebert, S. N., Howard, S. K. 2014; 118 (6): 1389-1390

    View details for DOI 10.1213/ANE.0000000000000176

    View details for PubMedID 24842188

  • Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical orthopaedics and related research Mudumbai, S. C., Kim, T. E., Howard, S. K., Workman, J. J., Giori, N., Woolson, S., Ganaway, T., King, R., Mariano, E. R. 2014; 472 (5): 1377-1383


    Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.We determined whether, after TKA, patients with adductor canal CPNB versus patients with femoral CPNB demonstrated (1) greater total ambulation distance on Postoperative Day (POD) 1 and 2 and (2) decreased daily opioid consumption, pain scores, and hospital length of stay.Between October 2011 and October 2012, 180 patients underwent primary TKA at our practice site, of whom 93% (n = 168) had CPNBs. In this sequential series, the first 102 patients had femoral CPNBs, and the next 66 had adductor canal CPNBs. The change resulted from a modification to our clinical pathway, which involved only a change to the block. An evaluator not involved in the patients' care reviewed their medical records to record the parameters noted above.Ambulation distances were higher in the adductor canal group than in the femoral group on POD 1 (median [10(th)-90(th) percentiles]: 37 m [0-90 m] versus 6 m [0-51 m]; p < 0.001) and POD 2 (60 m [0-120 m] versus 21 m [0-78 m]; p = 0.003). Adjusted linear regression confirmed the association between adductor canal catheter use and ambulation distance on POD 1 (B = 23; 95% CI = 14-33; p < 0.001) and POD 2 (B = 19; 95% CI = 5-33; p = 0.008). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups.Adductor canal CPNB may promote greater early postoperative ambulation compared to femoral CPNB after TKA without a reduction in analgesia. Future randomized studies are needed to validate our major findings.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1007/s11999-013-3197-y

    View details for PubMedID 23897505

  • Implementing emergency manuals: can cognitive AIDS help translate best practices for patient care during acute events? Anesthesia and analgesia Goldhaber-Fiebert, S. N., Howard, S. K. 2013; 117 (5): 1149-1161


    In this article, we address whether emergency manuals are an effective means of helping anesthesiologists and perioperative teams apply known best practices for critical events. We review the relevant history of such cognitive aids in health care, as well as examples from other high stakes industries, and describe why emergency manuals have a role in improving patient care during certain events. We propose 4 vital elements: create, familiarize, use, and integrate, necessary for the widespread, successful development, and implementation of medical emergency manuals, using the specific example of the perioperative setting. The details of each element are presented, drawing from the medical literature as well as from our combined experience of more than 30 years of observing teams of anesthesiologists managing simulated and real critical events. We emphasize the importance of training clinicians in the use of emergency manuals for education on content, format, and location. Finally, we discuss cultural readiness for change, present a system example of successful integration, and highlight the importance of further research on the implementation of emergency manuals.

    View details for DOI 10.1213/ANE.0b013e318298867a

    View details for PubMedID 24108251

  • An In Vitro Study to Evaluate the Utility of the "Air Test" to Infer Perineural Catheter Tip Location JOURNAL OF ULTRASOUND IN MEDICINE Kan, J. M., Harrison, T. K., Kim, T. E., Howard, S. K., Kou, A., Mariano, E. R. 2013; 32 (3): 529-533


    Injection of air under ultrasound guidance via a perineural catheter after insertion ("air test") has been described as a means to infer placement accuracy, yet this test has never been rigorously evaluated. We tested the hypothesis that the air test predicts accurate catheter location greater than chance and determined the test's sensitivity, specificity, and positive and negative predictive values using a porcine-bovine model and blinded expert in ultrasound-guided regional anesthesia. The air test improved the expert clinician's assessment of catheter tip position compared to chance, but there was no difference when compared to direct visualization of the catheter without air injection.

    View details for Web of Science ID 000315835900018

    View details for PubMedID 23443194

  • A Randomized Comparison of Long- and Short-Axis Imaging for In-Plane Ultrasound-Guided Femoral Perineural Catheter Insertion JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Kim, T. E., Funck, N., Walters, T., Wagner, M. J., Harrison, T. K., Giori, N., Woolson, S., Ganaway, T., Howard, S. K. 2013; 32 (1): 149-156


    Continuous femoral nerve blocks provide effective analgesia after knee arthroplasty, and infusion effects depend on reliable catheter location. Ultrasound-guided perineural catheter insertion using a short-axis in-plane technique has been validated, but the optimal catheter location relative to target nerve and placement orientation remain unknown. We hypothesized that a long-axis in-plane technique for femoral perineural catheter insertion results in faster onset of sensory anesthesia compared to a short-axis in-plane technique.Preoperatively, patients receiving an ultrasound-guided nonstimulating femoral perineural catheter for knee surgery were randomly assigned to either the long-axis in-plane or short-axis in-plane technique. A local anesthetic was administered via the catheter after successful insertion. The primary outcome was the time to achieve complete sensory anesthesia. Secondary outcomes included the procedural time, the onset time of the motor block, pain and muscle weakness reported on postoperative day 1, and procedure-related complications.The short-axis group (n = 23) took a median (10th-90th percentiles) of 9.0 (6.0-20.4) minutes compared to 6.0 (3.0-14.4) minutes for the long-axis group (n = 23; P = .044) to achieve complete sensory anesthesia. Short-axis procedures took 5.0 (4.0-7.8) minutes to perform compared to 9.0 (7.0-14.8) minutes for long-axis procedures (P < .001). In the short-axis group, 19 of 23 (83%) achieved a complete motor block within the testing period compared to 18 of 23 (78%) in the long-axis group (P = .813); short-axis procedures took 12.0 (6.0-15.0) minutes versus 15.0 (5.1-27.9) minutes for long-axis procedures (P = .048). There were no statistically significant differences in other secondary outcomes.Long-axis in-plane femoral perineural catheters result in a slightly faster onset of sensory anesthesia, but placement takes longer to perform without other clinical advantages.

    View details for Web of Science ID 000313607400017

    View details for PubMedID 23269720

  • Preliminary Study of Ergonomic Behavior During Simulated Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Display JOURNAL OF ULTRASOUND IN MEDICINE Udani, A. D., Harrison, T. K., Howard, S. K., Kim, T. E., Brock-Utne, J. G., Gaba, D. M., Mariano, E. R. 2012; 31 (8): 1277-1280


    A head-mounted display provides continuous real-time imaging within the practitioner's visual field. We evaluated the feasibility of using head-mounted display technology to improve ergonomics in ultrasound-guided regional anesthesia in a simulated environment. Two anesthesiologists performed an equal number of ultrasound-guided popliteal-sciatic nerve blocks using the head-mounted display on a porcine hindquarter, and an independent observer assessed each practitioner's ergonomics (eg, head turning, arching, eye movements, and needle manipulation) and the overall block quality based on the injectate spread around the target nerve for each procedure. Both practitioners performed their procedures without directly viewing the ultrasound monitor, and neither practitioner showed poor ergonomic behavior. Head-mounted display technology may offer potential advantages during ultrasound-guided regional anesthesia.

    View details for Web of Science ID 000306985100017

    View details for PubMedID 22837293

  • External Validation of Simulation-Based Assessments With Other Performance Measures of Third-Year Anesthesiology Residents SIMULATION IN HEALTHCARE Mudumbai, S. C., Gaba, D. M., Boulet, J. R., Howard, S. K., Davies, M. F. 2012; 7 (2): 73-80


    There has been interest in the use of high-fidelity medical simulation to evaluate performance. We hypothesized that technical and nontechnical performance in the simulated environment is related to other various criterion measures, providing evidence to support the validity of the scores from the performance-based assessment.Twelve third-year anesthesia residents participated in a series of 6 short 5-minute scenarios and 1 longer 30-minute scenario. The short scenarios measured technical skills, whereas the longer one focused on nontechnical skills. Two independent raters scored subjects using analytic and holistic ratings. Short scenarios involved acute hemorrhage, blocked endotracheal tube, bronchospasm, hyperkalemia, tension pneumothorax, and unstable ventricular tachycardia. The long scenario concerned management of myocardial ischemia/infarction leading to cardiac arrest. Scores from the simulations were correlated with (a) rankings generated from an Internet-based global ranking instrument that categorized residents based on overall clinical ability and (b) residency board scores.There were moderate correlations between various participant scores from the simulation-based assessment and aggregate rankings based on the global ranking instrument and residency examination scores.The associations between simulator performance, both for technical and nontechnical skills, and other markers of ability provide some evidence to support the validity of simulation-based assessment scores. Replication studies with larger numbers of residents are warranted.

    View details for DOI 10.1097/SIH.0b013e31823d018a

    View details for Web of Science ID 000302776800001

    View details for PubMedID 22374230

  • The Study of Factors Affecting Human and Systems Performance in Healthcare Using Simulation SIMULATION IN HEALTHCARE LeBlanc, V. R., Manser, T., Weinger, M. B., Musson, D., Kutzin, J., Howard, S. K. 2011; 6: S24-S29


    A large body of research using simulation in healthcare has focused on simulation itself as an object of research. However, simulation can also be used in research on human or system performance. It can be used to investigate the effects of performance shaping factors that would otherwise be difficult to study in the actual clinical setting due to practical constraints or ethical concerns. In this monograph, we illustrate various ways in which simulation has been used to study performance shaping factors. We also discuss possible directions for future research as well as methodological considerations for researchers engaging in this approach to study performance shaping factors.

    View details for DOI 10.1097/SIH.0b013e318229f5c8

    View details for Web of Science ID 000294209700005

    View details for PubMedID 21817860

  • Feasibility of an internet-based global ranking instrument. Journal of graduate medical education Mudumbai, S. C., Gaba, D. M., Boulet, J., Howard, S. K., Davies, M. F. 2011; 3 (1): 67-74


    Single-item global ratings are commonly used at the end of undergraduate clerkships and residency rotations to measure specific competencies and/or to compare the performances of individuals against their peers. We hypothesized that an Internet-based instrument would be feasible to adequately distinguish high- and low-ability residents.After receiving Institutional Review Board approval, we developed an Internet-based global ranking instrument to rank 42 third-year residents (21 in 2008 and 21 in 2009) in a major university teaching hospital's department of anesthesiology. Evaluators were anesthesia attendings and nonphysicians in 3 tertiary-referral hospitals. Evaluators were asked this ranking question: "When it comes to overall clinical ability, how does this individual compare to all their peers?"For 2008, 111 evaluators completed the ranking exercise; for 2009, 79 completed it. Residents were rank-ordered using the median of evaluator categorizations and the frequency of ratings per assigned relative performance quintile. Across evaluator groups and study years, the summary evaluation data consistently distinguished the top and bottom resident cohorts.An Internet-based instrument, using a single-item global ranking, demonstrated feasibility and can be used to differentiate top- and bottom-performing cohorts. Although ranking individuals yields norm-referenced measures of ability, successfully identifying poorly performing residents using online technologies is efficient and will be useful in developing and administering targeted evaluation and remediation programs.

    View details for DOI 10.4300/JGME-D-10-00162.1

    View details for PubMedID 22379525

  • Use of Medical Simulation to Explore Equipment Failures and Human-Machine Interactions in Anesthesia Machine Pipeline Supply Crossover ANESTHESIA AND ANALGESIA Mudumbai, S. C., Fanning, R., Howard, S. K., Davies, M. F., Gaba, D. M. 2010; 110 (5): 1292-1296


    High-fidelity medical simulation can be used to explore failure modes of technology and equipment and human-machine interactions. We present the use of an equipment malfunction simulation scenario, oxygen (O(2))/nitrous oxide (N(2)O) pipeline crossover, to probe residents' knowledge and their use of anesthetic equipment in a rapidly escalating crisis.In this descriptive study, 20 third-year anesthesia residents were paired into 10 two-member teams. The scenario involved an Ohmeda Modulus SE 7500 anesthetic machine with a Datex AS/3 monitor that provided vital signs and gas monitoring. Before the scenario started, we switched pipeline connections so that N(2)O entered through the O(2) pipeline and vice versa. Because of the switched pipeline, the auxiliary O(2) flowmeter delivered N(2)O instead of O(2). Two expert, independent raters reviewed videotaped scenarios and recorded the alarms explicitly noted by participants and methods of ventilation.Nine pairs became aware of the low fraction of inspired O(2) (Fio(2)) alarm. Only 3 pairs recognized the high fraction of inspired N(2)O (Fin(2)o) alarm. One group failed to recognize both the low Fio(2) and the high Fin(2)o alarms. Nine groups took 3 or more steps before instigating a definitive route of oxygenation. Seven groups used the auxiliary O(2) flowmeter at some point during the management steps.The fact that so many participants used the auxiliary O(2) flowmeter may expose machine factors and related human-machine interactions during an equipment crisis. Use of the auxiliary O(2) flowmeter as a presumed external source of O(2) contributed to delays in definitive treatment. Many participants also failed to notice the presence of high N(2)O. This may have been, in part, attributable to 2 facts that we uncovered during our video review: (a) the transitory nature of the "high N(2)O" alert, and (b) the dominance of the low Fio(2) alarm, which many chose to mute. We suggest that the use of high-fidelity simulations may be a promising avenue to further examine hypotheses related to failure modes of equipment and possible management response strategies of clinicians.

    View details for DOI 10.1213/ANE.0b013e3181d7e097

    View details for Web of Science ID 000277130700010

    View details for PubMedID 20418294

  • Coordination Patterns Related to High Clinical Performance in a Simulated Anesthetic Crisis ANESTHESIA AND ANALGESIA Manser, T., Harrison, T. K., Gaba, D. M., Howard, S. K. 2009; 108 (5): 1606-1615


    Teamwork is an integral component in the delivery of safe patient care. Several studies highlight the importance of effective teamwork and the need for teams to respond dynamically to changing task requirements, for example, during crisis situations. In this study, we address one of the many facets of "effective teamwork" in medical teams by investigating coordination patterns related to high performance in the management of a simulated malignant hyperthermia (MH) scenario. We hypothesized that (a) anesthesia crews dynamically adapt their work and coordination patterns to the occurrence of a simulated MH crisis and that (b) crews with higher clinical performance scores (based on a time-based scoring system for critical MH treatment steps) exhibit different coordination patterns.This observational study investigated differences in work and coordination patterns of 24 two-person anesthesia crews in a simulated MH scenario. Clinical and coordination behavior were coded using a structured observation system consisting of 36 mutually exclusive observation categories for clinical activities, coordination activities, teaching, and other communication. Clinical performance scores for treating the simulated episode of MH were calculated using a time-based scoring system for critical treatment steps. Coordination patterns in response to the occurrence of a crisis situation were analyzed using multivariate analysis of variance and the relationship between coordination patterns and clinical performance was investigated using hierarchical regression analyses. Qualitative analyses of the three highest and lowest performing crews were conducted to complement the quantitative analysis.First, a multivariate analysis of variance revealed statistically significant changes in the proportion of time spent on clinical and coordination activities once the MH crisis was declared (F [5,19] = 162.81, P < 0.001, eta(p)(2) = 0.98). Second, hierarchical regression analyses controlling for the effects of cognitive aid use showed that higher performing anesthesia crews exhibit statistically significant less task distribution (beta = -0.539, P < 0.01) and significantly more situation assessment (beta = 0.569, P < 0.05). Additional qualitative video analysis revealed, for example, that lower scoring crews were more likely to split into subcrews (i.e., both anesthesiologists worked with other members of the perioperative team without maintaining a shared plan among the two-person anesthesia crew).Our results of the relationship of coordination patterns and clinical performance will inform future research on adaptive coordination in medical teams and support the development of specific training to improve team coordination and performance.

    View details for DOI 10.1213/ane.0b013e3181981d36

    View details for Web of Science ID 000265422300040

    View details for PubMedID 19372344

  • Improvement in coronary anastomosis with cardiac surgery simulation JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Caffarelli, A. D., Georgette, G., Howard, S. K., Gaba, D. M., Youngblood, P., Mitchell, S., Burdon, T. A. 2008; 136 (6): 1486-1491


    Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis.Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed.Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training.In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.

    View details for DOI 10.1016/j.jtcvs.2008.08.016

    View details for PubMedID 19114195

  • Trauma training in simulation: Translating skills from SIM time to real time 66th Annual Meeting of the American-Association-for-the-Surgery-of-Trauma Knudson, M. M., Khaw, L., Bullard, M. K., Dicker, R., Cohen, M. J., Staudenmayer, K., Sadjadi, J., Howard, S., Gaba, D., Krummel, T. LIPPINCOTT WILLIAMS & WILKINS. 2008: 255–63


    : Training surgical residents to manage critically injured patients in a timely fashion presents a significant challenge. Simulation may have a role in this educational process, but only if it can be demonstrated that skills learned in a simulated environment translate into enhanced performance in real-life trauma situations.: A five-part, scenario-based trauma curriculum was developed specifically for this study. Midlevel surgical residents were randomized to receiving this curriculum in didactic lecture (LEC) fashion or with the use of a human performance simulator (HPS). A written learning objectives test was administered at the completion of the training. The first four major trauma resuscitations performed by each participating resident were captured on videotape in the emergency department and graded by two experienced judges blinded to the method of training. The assessment tool used by the judges included an evaluation of both initial trauma evaluation or treatment skills (part I) and crisis management skills (part II) as well as an overall score (poor/fail, adequate, or excellent).: The two groups of residents received almost identical scores on the posttraining written test. Average SIM and LEC scores for part I were also similar between the two groups. However, SIM-trained residents received higher overall scores and higher scores for part II crisis management skills compared with the LEC group, which was most evident in the scores received for the teamwork category (p = 0.04).: A trauma curriculum incorporating simulation shows promise in developing crisis management skills that are essential for evaluation of critically injured patients.

    View details for DOI 10.1097/TA.0b013e31816275b0

    View details for Web of Science ID 000253287100001

    View details for PubMedID 18301184

  • Adaptive coordination in cardiac anaesthesia: a study of situational changes in coordination patterns using a new observation system ERGONOMICS Manser, T., Howard, S. K., Gaba, D. M. 2008; 51 (8): 1153-1178


    Patient care in hospital settings requires coordinated team performance. Studies in other industries show that successful teams adapt their coordination processes to the situational task requirements. This prospective field study aimed to test a new observation system and investigate patterns of adaptive coordination within operating room teams. A trained observer recorded coordination activities during 24 cardiac surgery procedures. The study tested whether different patterns occur during different phases of and between different types of surgical procedures (two-way multivariate ANOVA with repeated measure). A statistically significant increase was found in clinical and coordination activities in phases of the operation with high task interdependence. The highest level of 'coordination via the work environment' (i.e. an implicit coordination mechanism) was recorded during the actual procedure on the beating heart. These findings prove the sensitivity of the observation system developed and evaluated in this study and provide insight into patterns of adaptive coordination in cardiac anaesthesia. This study furthers our understanding of adaptive coordination as a cornerstone of effective team performance in complex work environments. Using a new observation system, it describes patterns employed by health care professionals in response to changing task demands in an acute patient care setting.

    View details for DOI 10.1080/00140130801961919

    View details for Web of Science ID 000257544400003

    View details for PubMedID 18608475

  • Using the rapid response system to provide better oversight of patient care processes. Joint Commission journal on quality and patient safety / Joint Commission Resources Moore, M. S., Howard, S. K., Lighthall, G. 2007; 33 (11): 695-?


    The cross-disciplinary nature of patient care and medical emergency teams allows for identification of systemwide problems that might otherwise be perceived as isolated events.

    View details for PubMedID 18074718

  • Cognitive aids in a simulated anesthetic crisis - Response ANESTHESIA AND ANALGESIA Harrison, T. K., Manser, T., Howard, S. K., Gaba, D. M. 2007; 104 (5): 1293-1293
  • Improving alertness and performance in emergency department physicians and nurses: The use of planned naps ANNALS OF EMERGENCY MEDICINE Smith-Coggins, R., Howard, S. K., Mac, D. T., Wang, C., Kwan, S., Rosekind, M. R., Sowb, Y., Ballise, R., Levis, J., Gaba, D. M. 2006; 48 (5): 596-604


    We examine whether a 40-minute nap opportunity at 3 AM can improve cognitive and psychomotor performance in physicians and nurses working 12-hour night shifts.This is a randomized controlled trial of 49 physicians and nurses working 3 consecutive night shifts in an academic emergency department. Subjects were randomized to a control group (no-nap condition=NONE) or nap intervention group (40-minute nap opportunity at 3 AM=NAP). The main outcome measures were Psychomotor Vigilance Task, Probe Recall Memory Task, CathSim intravenous insertion virtual reality simulation, and Profile of Mood States, which were administered before (6:30 PM), during (4 AM), and after (7:30 AM) night shifts. A 40-minute driving simulation was administered at 8 AM and videotaped for behavioral signs of sleepiness and driving accuracy. During the nap period, standard polysomnographic data were recorded.Polysomnographic data revealed that 90% of nap subjects were able to sleep for an average of 24.8 minutes (SD 11.1). At 7:30 AM, the nap group had fewer performance lapses (NAP 3.13, NONE 4.12; p<0.03; mean difference 0.99; 95% CI: -0.1-2.08), reported more vigor (NAP 4.44, NONE 2.39; p<0.03; mean difference 2.05; 95% CI: 0.63-3.47), less fatigue (NAP 7.4, NONE 10.43; p<0.05; mean difference 3.03; 95% CI: 1.11-4.95), and less sleepiness (NAP 5.36, NONE 6.48; p<0.03; mean difference 1.12; 95% CI: 0.41-1.83). They tended to more quickly complete the intravenous insertion (NAP 66.40 sec, NONE 86.48 sec; p=0.10; mean difference 20.08; 95% CI: 4.64-35.52), exhibit less dangerous driving and display fewer behavioral signs of sleepiness during the driving simulation. Immediately after the nap (4 AM), the subjects scored more poorly on Probed Recall Memory (NAP 2.76, NONE 3.7; p<0.05; mean difference 0.94; 95% CI: 0.20-1.68).A nap at 3 AM improved performance and subjective report in physicians and nurses at 7:30 AM compared to a no-nap condition. Immediately after the nap, memory temporarily worsened. The nap group did not perform any better than the no-nap group during a simulated drive home after the night shift.

    View details for DOI 10.1016/j.annemergmed.2006.02.005

    View details for Web of Science ID 000241749400017

    View details for PubMedID 17052562

  • Use of cognitive aids in a simulated anesthetic crisis ANESTHESIA AND ANALGESIA Harrison, T. K., Manser, T., Howard, S. K., Gaba, D. M. 2006; 103 (3): 551-556


    We evaluated empirically the extent to which the use of a cognitive aid during a high-fidelity simulation of a malignant hyperthermia (MH) event facilitated the correct and prompt treatment of MH. We reviewed the management of 48 simulated adult MH scenarios; 24 involving CA 1 and 24 involving CA 2 residents. In the CA 1 group, 19 of the 24 teams (79%) used a cognitive aid, but only 8 of the 19 teams used it frequently or extensively. In the CA 2 group, 18 of the 23 teams (78%) used a cognitive aid but only 6 of them used it frequently or extensively. The frequency of cognitive aid use correlated significantly with the MH treatment score for the CA 1 group (Spearman r = 0.59, P < 0.01) and CA 2 group (Spearman r = 0.68, P < 0.001). The teams that performed the best in treating MH used a cognitive aid extensively throughout the simulation. Although the effect was less pronounced in the more experienced CA 2 cohort, there was still a strong correlation between performance and cognitive aid use. We were able to show a strong correlation between the use of a cognitive aid and the correct treatment of MH.

    View details for DOI 10.1213/01.ane.0000229718.02478.c4

    View details for Web of Science ID 000240049800007

    View details for PubMedID 16931660

  • Re: The impact of sleep deprivation on product quality and procedure effectiveness in a laparoscopic physical simulator. American journal of surgery Nevarez, M. D., Howard, S. K. 2006; 192 (1): 139-?

    View details for PubMedID 16769292

  • So many roads: facilitated debriefing in healthcare. Simulation in healthcare Dismukes, R. K., Gaba, D. M., Howard, S. K. 2006; 1 (1): 23-25

    View details for PubMedID 19088569

  • Clinicians' recognition of the Ohmeda Modulus II plus and Ohmeda Excel 210 SE anesthesia machine system mode and function. Simulation in healthcare Sowb, Y. A., Howard, S. K., Raemer, D. B., Feinstein, D., Fish, K. J., Gaba, D. M. 2006; 1 (1): 26-31


    : Anesthesiologists' cognitive resources such as their attention, knowledge, and strategies play an important role in the prevention and correction of critical events. In this paper, we examined anesthesiologists' responses to the anesthesia machine (AM) in the "off" position during a simulated emergent cesarean section scenario.: All simulations were videotaped which allowed for offline review. At the beginning of the scenario, the AM system switch was purposefully turned to the off/standby position. The responses of 14 anesthesia residents at the Veterans Affairs Palo Alto Health Care System and Stanford University Simulation Center for Crisis Management Training in Health Care (VASC) and 11 anesthesia residents at the Boston Center for Medical Simulation (CMS) were analyzed.: Nine subjects at VASC restored the AM system switch to the "on" position on their own, whereas five subjects required help from another clinician. The median response time (RT) for all 14 subjects was 149.5 seconds. At CMS, five subjects restored the AM system switch to the "on" position on their own (median RT = 207 seconds), whereas two subjects received help from another anesthesia resident. There were four cases where the AM system switch problem was not corrected.: Factors that could have contributed to subjects' difficulty in detecting and correcting the AM system switch included the unusual nature of the problem, the human factors design of the AM front panel and system switch, and inadequate training by the subjects. Improving the appearance of the AM's system switch and training of clinicians to recognize the location and functionality of the AM system switch could be useful in correcting such an event in a timely manner and reducing patient risk.

    View details for PubMedID 19088570

  • Clinicians' recognition of the Ohmeda Modulus II Plus and Ohmeda Excel 210 SE anesthesia machine system mode and function Simulation in Healthcare Sowb, Y., Howard SK, Raemer DB, Feinstein D, Fish KJ, Gaba DM 2006; 1 (1): 26-31
  • So many roads: Faciltiated debriefing in healthcare Simulation in Healthcare Dismukes, R., Gaba DM, Howard SK 2006; 1 (1): 23-25
  • Sleep deprivation and physician performance: why should I care? Proceedings (Baylor University. Medical Center) Howard, S. K. 2005; 18 (2): 108-112

    View details for PubMedID 16200156

  • Sleep propensity and performance: Evaluating a brief protocol in health care providers 19th Annual Meeting of the Associated-Professional-Sleep-Societies Howard, S. K., Smith-Coggins, R., Nevarez, M., Sohoni, A., Gaba, D., Rosekind, M. AMER ACAD SLEEP MEDICINE. 2005: A133–A133
  • Measuring sleep onset: Comparing the standard versus an experimental montage 19th Annual Meeting of the Associated-Professional-Sleep-Societies Howard, S. K., Smith-Coggins, R., Nevarez, M., Sohoni, A., Gaba, D., Rosekind, M. AMER ACAD SLEEP MEDICINE. 2005: A324–A325
  • Preparing physicians for the real world - Dr. Howard responds CANADIAN MEDICAL ASSOCIATION JOURNAL Howard, S. K. 2004; 171 (7): 709-710
  • Validation of simulation-based training in neonatal resuscitation: Use of heart rate variability as marker for mental workload Annual Meeting of the Pediatric-Academic-Societies Murphy, A. A., Kaegi, D. M., Gobble, R., Dubin, A., Howard, S. K., Gaba, D. M., Sowb, Y. A., Halamek, L. P. NATURE PUBLISHING GROUP. 2004: 353A–353A
  • Trainee fatigue: Are new limits on work hours enough? CANADIAN MEDICAL ASSOCIATION JOURNAL Howard, S. K., Gaba, D. M. 2004; 170 (6): 975-976

    View details for Web of Science ID 000220242700028

    View details for PubMedID 15023924

  • Use of a fully simulated intensive care unit environment for critical event management training for internal medicine residents CRITICAL CARE MEDICINE Lighthall, G. K., Barr, J., Howard, S. K., Gellar, E., Sowb, Y., Bertacini, E., Gaba, D. 2003; 31 (10): 2437-2443
  • Simulation study of rested versus sleep-deprived anesthesiologists ANESTHESIOLOGY Howard, S. K., Gaba, D. M., Smith, B. E., Weinger, M. B., Herndon, C., Keshavacharya, S., Rosekind, M. R. 2003; 98 (6): 1345-1355


    Sleep deprivation causes physiologic and subjective sleepiness. Studies of fatigue effects on anesthesiologist performance have given equivocal results. The authors used a realistic simulation environment to study the effects of sleep deprivation on psychomotor and clinical performance, subjective and objective sleepiness, and mood.Twelve anesthesia residents performed a 4-h anesthetic on a simulated patient the morning after two conditions of prior sleep: sleep-extended (EXT), in which subjects were allowed to arrive at work at 10:00 AM for 4 consecutive days, thus allowing an increase in nocturnal sleep time, and total sleep deprivation (DEP), in which subjects were awake at least 25 h. Psychomotor testing was performed at specified periods throughout the night in the DEP condition and at matched times during the simulation session in both conditions. Three types of vigilance probes were presented to subjects at random intervals as well as two clinical events. Task analysis and scoring of alertness were performed retrospectively from videotape.In the EXT condition, subjects increased their sleep by more than 2 h from baseline (P = 0.0001). Psychomotor tests revealed progressive impairment of alertness, mood, and performance in the DEP condition over the course of the night and when compared with EXT during the experimental day. DEP subjects showed longer response latency to vigilance probes, although this was statistically significant for only one probe type. Task analysis showed no difference between conditions except that subjects "slept" more in the DEP condition. There was no significant difference in the cases' clinical management between sleep conditions. Subjects in the DEP condition had lower alertness scores (P = 0.02), and subjects in the EXT condition showed little video evidence of sleepiness.Psychomotor performance and mood were impaired while subjective sleepiness and sleepy behaviors increased during simulated patient care in the DEP condition. Clinical performance between conditions was similar.

    View details for Web of Science ID 000183075400007

    View details for PubMedID 12766642

  • Emergency medicine crisis resource management (EMCRM): Pilot study of a simulation-based crisis management course for emergency medicine ACADEMIC EMERGENCY MEDICINE Reznek, M., Smith-Coggins, R., Howard, S., Kiran, K., Harter, P., Sowb, Y., Gaba, D., Krummel, T. 2003; 10 (4): 386-389


    To determine participant perceptions of Emergency Medicine Crisis Resource Management (EMCRM), a simulation-based crisis management course for emergency medicine.EMCRM was created using Anesthesia Crisis Resource Management (ACRM) as a template. Thirteen residents participated in one of three pilot courses of EMCRM; following a didactic session on principles of human error and crisis management, the residents participated in simulated emergency department crisis scenarios and instructor-facilitated debriefing. The crisis simulations involved a computer-enhanced mannequin simulator and standardized patients. After finishing the course, study subjects completed a horizontal numerical scale survey (1 = worst rating to 5 = best rating) of their perceptions of EMCRM. Descriptive statistics were calculated to evaluate the data.The study subjects found EMCRM to be enjoyable (4.9 +/- 0.3) (mean +/- SD) and reported that the knowledge gained from the course would be helpful in their practices (4.5 +/- 0.6). The subjects believed that the simulation environment prompted realistic responses (4.6 +/- 0.8) and that the scenarios were highly believable (4.8 +/- 0.4). The participants reported that EMCRM was best suited for residents (4.9 +/- 0.3) but could also benefit students and attending physicians. The subjects believed that the course should be repeated every 8.2 +/- 3.3 months.The EMCRM participants rated the course very favorably and believed that the knowledge gained would be beneficial in their practices. The extremely positive response to EMCRM found in this pilot study suggests that this training modality may be valuable in training emergency medicine residents.

    View details for Web of Science ID 000181995500016

    View details for PubMedID 12670855

  • The culture of safety: results of an organization-wide survey in 15 California hospitals QUALITY & SAFETY IN HEALTH CARE Singer, S. J., Gaba, D. M., Geppert, J. J., Sinaiko, A. D., Howard, S. K., Park, K. C. 2003; 12 (2): 112-118


    To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings.15 hospitals participating in the California Patient Safety Consortium.A sample of 6312 employees generally comprising all the hospital's attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response.Frequency of responses suggesting an absence of safety culture ("problematic responses" to survey questions) and the frequency of "neutral" responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status.The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers.Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

    View details for Web of Science ID 000182156000011

    View details for PubMedID 12679507

  • Fatigue in anesthesia - Implications and strategies for patient and provider safety ANESTHESIOLOGY Howard, S. K., Rosekind, M. R., Katz, J. D., Berry, A. J. 2002; 97 (5): 1281-1294

    View details for Web of Science ID 000179034600034

    View details for PubMedID 12411816

  • Patient safety: Fatigue among clinicians and the safety of patients NEW ENGLAND JOURNAL OF MEDICINE Gaba, D. M., Howard, S. K. 2002; 347 (16): 1249-1255

    View details for Web of Science ID 000178598300007

    View details for PubMedID 12393823

  • The risks and implications of excessive daytime sleepiness in resident physicians ACADEMIC MEDICINE Howard, S. K., Gaba, D. M., Rosekind, M. R., Zarcone, V. P. 2002; 77 (10): 1019-1025


    To assess the levels of physiologic and subjective sleepiness in residents in three conditions: (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hour on-call period, and (3) following a period of extended sleep.In 1996, a within-subjects, repeated-measures study was performed with a volunteer sample of 11 anesthesia residents from the Stanford University School of Medicine using three separate experimental conditions. Sixteen residents were recruited and 11 of the 16 completed the three separate experimental conditions. Daytime sleepiness was assessed using the Multiple Sleep Latency Test (MSLT).MSLT scores were shorter in the baseline (6.7 min) and post-call (4.9 min) conditions, compared with the extended-sleep condition (12 min, p =.0001) and there was no significant difference between the baseline and post-call conditions (p =.07). There was a significant main effect for both condition (p =.0001) and time of day (p =.0003). Subjects were inaccurate in subjectively identifying sleep onset compared with EEG measures (incorrect on 49% of EEG-determined sleep episodes).Residents' daytime sleepiness in both baseline and post-call conditions was near or below levels associated with clinical sleep disorders. Extending sleep time resulted in normal levels of daytime sleepiness. The residents were subjectively inaccurate determining EEG-defined sleep onset. Based on the findings from this and other studies, reforms of residents' work and duty hours are justified.

    View details for Web of Science ID 000179365700013

    View details for PubMedID 12377678

  • Do naps during the night shift improve performance in the emergency department? Smith-Coggins, R., Howard, S., KWAN, S., Wang, C., Rosekind, M., Sowb, Y., Balise, R., Gaba, D. AMER ACAD SLEEP MEDICINE. 2002: A116–A117
  • Use of a high fidelity patient simulator to teach crisis resource management to internal medicine residents rotating through the ICU: A formative evaluation case study. Fischer, M., Howard, S., Geller, A. SPRINGER. 2002: 224–224
  • Time for a new paradigm in pediatric medical education: Teaching neonatal resuscitation in a simulated delivery room environment PEDIATRICS Halamek, L. P., Kaegi, D. M., Gaba, D. M., Sowb, Y. A., Smith, B. C., Smith, B. E., Howard, S. K. 2000; 106 (4)


    Acquisition and maintenance of the skills necessary for successful resuscitation of the neonate are typically accomplished by a combination of completion of standardized training courses using textbooks, videotape, and manikins together with active participation in the resuscitation of human neonates in the real delivery room. We developed a simulation-based training program in neonatal resuscitation (NeoSim) to bridge the gap between textbook and real life and to assess trainee satisfaction with the elements of this program.Thirty-eight subjects (physicians and nurses) participated in 1 of 9 full-day NeoSim programs combining didactic instruction with active, hands-on participation in intensive scenarios involving life-like neonatal and maternal manikins and real medical equipment. Subjects were asked to complete an extensive evaluation of all elements of the program on its conclusion.The subjects expressed high levels of satisfaction with nearly all aspects of this novel program. Responses to open-ended questions were especially enthusiastic in describing the realistic nature of simulation-based training. The major limitation of the program was the lack of fidelity of the neonatal manikin to a human neonate.Realistic simulation-based training in neonatal resuscitation is possible using current technology, is well received by trainees, and offers benefits not inherent in traditional paradigms of medical education.

    View details for PubMedID 11015540

  • Simulators in anesthesiology education ANESTHESIA AND ANALGESIA Gaba, D. M., Howard, S., Smith, B., Weinger, M. B. 1999; 89 (3): 805-806
  • Effect of mental stress on heart rate variability: Validation of simulated operating and delivery room training modules Kaegi, D. M., Halamek, L. P., Van Hare, G. F., Howard, S. K., Dubin, A. M. NATURE PUBLISHING GROUP. 1999: 77A–77A
  • Factors influencing vigilance and performance of anesthetists. Current opinion in anaesthesiology Howard, S. K., Gaba, D. M. 1998; 11 (6): 651-657


    As a group, anesthetists have been the leaders in medicine in the study of vigilance, performance, and safety. This review updates the work that has been done in the last year regarding the study of anesthetist vigilance and performance. Much of this work has been performed with the use of patient simulators.

    View details for PubMedID 17013286

  • Behavioral evidence of fatigue during a simulator experiment Howard, S. K., Keshavacharya, S., Smith, B. E., Rosekind, M. R., Weinger, M., Gaba, D. M. LIPPINCOTT WILLIAMS & WILKINS. 1998: U975–U975
  • Assessing the fidelity of the simulated delivery room for neonatal resuscitation. Kaegi, D. M., Halamek, L. P., Howard, S. K., Smith, B. E., Gaba, D. M., Sowb, Y. A. AMER ACAD PEDIATRICS. 1998: 767–68
  • Use of task analysis to evaluate the effects of fatigue on performance during simulated anesthesia cases. Herndon, C. N., Weinger, M. B., Smith, B. E., Howard, S. K., Rosekind, M. R., Gaba, D. M. LIPPINCOTT WILLIAMS & WILKINS. 1998: U947–U947
  • Heart rate variability as a marker for workload during neonatal resuscitation Kaegi, D. M., Halamek, L. P., Dubin, A., Howard, S. AMER ACAD PEDIATRICS. 1998: 766–67
  • Attitudes toward production pressure and patient safety: A survey of anesthesia residents JOURNAL OF CLINICAL MONITORING AND COMPUTING Healzer, J. M., Howard, S. K., Gaba, D. M. 1998; 14 (2): 145-146

    View details for Web of Science ID 000073777000010

    View details for PubMedID 9669453

  • The simulated delivery room as a laboratory for the study of human performance. Halamek, L. P., Howard, S. K., Kaegi, D. M., Smith, B. E., Smith, B. C., Gaba, D. M. LIPPINCOTT WILLIAMS & WILKINS. 1998: 167A–167A
  • Simulated anaesthetic emergencies BRITISH JOURNAL OF ANAESTHESIA Gaba, D. M., Howard, S. K. 1997; 79 (5): 689-690

    View details for Web of Science ID A1997YC73300030

    View details for PubMedID 9422915

  • Development of a simulated delivery room for the study of human performance during neonatal resuscitation Halamek, L. P., Howard, S. K., Smith, B. E., Smith, B. C., Gaba, D. M. AMER ACAD PEDIATRICS. 1997: 513–14
  • Sleep and work schedules of anesthesia residents: A national survey Howard, S. K., Healzer, J. M., Gaba, D. M. LIPPINCOTT WILLIAMS & WILKINS. 1997: A932–A932
  • Performance of well-rested vs. highly-fatigued residents: A simulator study Howard, S. K., Smith, B. E., Gaba, D. M., Rosekind, M. R. LIPPINCOTT WILLIAMS & WILKINS. 1997: A981–A981
  • Anesthetic considerations for port-access cardiac surgery Siegel, L. C., Peters, W. S., STGOAR, F. G., Stevens, J. H., Pompili, M. F., Howard, S. K., Burdon, T. A., Ribakove, G. H., Mitchell, R. S. LIPPINCOTT WILLIAMS & WILKINS. 1996: SCA79–SCA79


    Situation awareness has primarily been confined to the aviation field. We believe that situation awareness is an equally important characteristic in the complex, dynamic, and risky field of anesthesiology. We describe three aspects of situations of which the decision maker must remain aware: subtle cues, evolving situations, and special knowledge elements. We provide examples of real or simulated anesthesia situations in which situation awareness is clearly involved in the provision of optimal patient care, and we map the elements of situation awareness onto a cognitive process model of the anesthesiologist. Finally, we consider how situation awareness can be further investigated and taught in this medical domain using anesthesia simulators and analyses of real cases. The study of situation awareness in anesthesiology may provide a good example of the wider application of the concept of situation awareness to nonaerospace environments.

    View details for Web of Science ID A1995RL73500003

    View details for PubMedID 7790008



    Pressure to put efficiency, output, or continued production ahead of safety has caused catastrophic accidents in various industries. The authors assessed the attitudes and experiences of anesthesiologists concerning production pressure.A random, repeated-mailing survey was conducted among 647 members of the American Society of Anesthesiologists residing in California. Questions were asked about attitudes toward production pressure and other patient safety issues, frequency of occurrence of various operating room events, encounters with situations involving unsafe actions, and ratings of sources of production pressure.Forty-seven percent of those sampled returned surveys. The demographics of the respondent population were largely similar to those of the population of anesthesiologists in California. There was no systematic difference between the respondents to the first versus the second mailing, reducing (but not eliminating) the possibility of self-selection bias. Nearly half (49%) of respondents had witnessed production pressure result in what they believed to be unsafe actions by an anesthesiologist. Such events included elective surgery in patients without adequate evaluation or with significant contraindications to surgery. Anesthesiologists felt pressures within themselves to work agreeably with surgeons, avoid delaying cases, and avoid litigation. They also reported overt pressure by surgeons to proceed with cases instead of cancelling them, and to hasten anesthetic procedures. Some aspects of production pressure were perceived differently by those reimbursed by fee-for-service versus those paid by salary.Production pressure from internal and external sources is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions being performed.

    View details for Web of Science ID A1994PA47900026

    View details for PubMedID 8053599



    The authors have developed a course in Anesthesia Crisis Resource Management (ACRM) analogous to courses in Crew (Cock-pit) Resource Management (CRM) conducted in commercial and military aviation. Anesthesiologists do not typically receive formal training in crisis management although they are called upon to manage life-threatening crises at a moment's notice. Two model demonstration courses in ACRM were conducted using a realistic anesthesia simulation system to test the feasibility and acceptance of this kind of training. Anesthesiologists received didactic instruction in dynamic decision-making, human performance issues in anesthesia, and in the principles of anesthesia crisis resource management. After familiarization with the host institution's operating rooms and with the simulation environment, they underwent a 2-h simulation session followed by a debriefing session which used a videotape of their simulator performance. Participants rated the course as intense, helpful to their practice of anesthesiology, and highly enjoyable. Several aspects of the course were highly rated, including: videotapes of actual anesthetic mishaps, simulation sessions, and debriefing sessions. Scores on written tests of knowledge about anesthesia crisis management showed a significant improvement following the first course (residents) but not the second course (experienced anesthesiologists). Although the ultimate utility of this training for anesthesiologists cannot easily be determined, the course appeared to be a useful method for addressing important issues of anesthesiologist performance which have previously been dealt with haphazardly. The authors believe that ACRM training should become a regular part of the initial and continuing education of anesthesiologists.

    View details for Web of Science ID A1992JK72800001

    View details for PubMedID 1524531

  • Conference on human error in anesthesia (meeting report). Anesthesiology Howard S.K., Gaba D.M. 1991: 553-554