Circulation 122,210 • Volume 32, No. 2 • October 2017   Issue PDF

Simulation-Based Evaluation Among Board-Certified Anesthesiologists Managing Adverse Events

Steven Greenberg, MD, FCCP, FCCM; Matthew Weinger, MD

Objective measurement of the performance of experienced anesthesiologists during unexpected perioperative acute events is challenging. To address this issue, a national consortium recently performed a novel prospective, nonrandomized, observational study at eight simulation network group sites to quantify the technical and behavioral performances of 263 board-certified anesthesiologists.1 Four scenarios (local anesthetic toxicity with hemodynamic collapse, hemorrhagic shock, malignant hyperthermia, and acute onset of atrial fibrillation with subsequent cardiac ischemia) were created for standardized delivery across study sites. Subject matter experts (who were either oral or written ABA examiners) used a Delphi process to select 72 total critical performance elements (CPEs) that were deemed essential to effective patient management in these scenarios. Anesthesiologists attending existing MOCA simulation courses volunteered to be in the study. Each of their simulation encounters was video recorded for subsequent scoring by blinded, trained raters using specific validated checklists for the CPEs as well as holistic ratings of medical/technical and behavioral/non-technical performance.

The results, in the September 2017 issue of Anesthesiology,1 found that approximately 75% of CPEs were performed, and the majority of performances were scored as average or better on the rating scale. However, approximately 25% of all clinicians’ performances were deemed as poor, often where several CPEs were missed. Overall, the following failure modes were observed: failure to escalate therapy when initial response was ineffective, failure to discuss critical issues or raise concerns with other team members, failure to use all available resources (e.g., call for help), and failure to follow evidence-based guidelines.1 Performance deficiencies were seen in both the medical/technical (e.g., treatment decisions) and behavioral/non-technical (e.g., communication, teamwork) domains. Interestingly higher-rated performances were associated with younger age but not with previous simulation experience. The presence of a second anesthesiologist improved overall performance and those who failed to call for help did less well.

As pointed out in an accompanying editorial,2 in this simulation study, participants were not practicing in their familiar work environment and may not have recently experienced or reviewed the specific events manifested in the study scenarios. Therefore, caution should be used when drawing conclusions from the study. However, the findings suggest that more could be done to assure that anesthesia professionals have the most current knowledge, skills, and support to manage rare life-threatening events. Specifically, strategies to strengthen team performance during acute critical situations (such as emergency manuals or simulation) may be warranted even for experienced clinicians. Further research is required to more clearly delineate opportunities for improvement of experienced anesthesia professionals’ crisis event management and to understand how our field can strengthen every professional’s lifelong learning.

This research-based study was partially funded by the Anesthesia Patient Safety Foundation, the Agency for Healthcare Research and Quality, and by a grant from the Foundation for Anesthesia Education and Research.

Dr. Greenberg is presently Co-Editor of the APSF Newsletter and Vice Chairperson of Education in the Department of Anesthesiology at NorthShore University HealthSystems in Evanston, IL.

Dr. Weinger presently serves as Secretary of the APSF executive committee and is Professor in the Department of Anesthesiology at Vanderbilt University Medical Center.

Dr. Greenberg has no disclosures pertaining to this article. Dr. Weinger served as primary author of the study discussed.


  1. Weinger MB, Banerjee A, Burden AR, et al. Simulation-based assessment of the management of critical events by board-certified anesthesiologists. Anesthesiology 2017;127:475-489.
  2. Lien CA, Warner, MA, Rathmell JP. Simulation for asssessment of the practice of board-certified anesthesiologists. Anesthesiology 2017;127:410-412.