PDF(Pubmed)
Abstract：
BACKGROUND: Although safety climate, teamwork, and other non-technical skills in operating rooms probably influence clinical outcomes, direct associations have not been shown, at least partially due to sample size considerations. We report data from a retrospective cohort of anesthesia evaluations that can simplify the design of prospective observational studies in this area. Associations between non-technical skills in anesthesia, specifically anesthesiologists\' quality of clinical supervision and nurse anesthetists\' work habits, and patient and operational factors were examined.
METHODS: Eight fiscal years of evaluations and surgical cases from one hospital were included. Clinical supervision by anesthesiologists was evaluated daily using a nine-item scale. Work habits of nurse anesthetists were evaluated daily using a six-item scale. The dependent variables for both groups of staff were binary, whether all items were given the maximum score or not. Associations were tested with patient and operational variables for the entire day.
RESULTS: There were 40,718 evaluations of faculty anesthesiologists by trainees, 53,772 evaluations of nurse anesthetists by anesthesiologists, and 296,449 cases that raters and ratees started together. Cohen\'s d values were small (≤0.10) for all independent variables, suggesting a lack of any clinically meaningful association between patient and operational factors and evaluations given the maximum scores. For supervision quality, the day\'s count of orthopedic cases was a significant predictor of scores (P = 0.0011). However, the resulting absolute marginal change in the percentage of supervision scores equal to the maximum was only 0.8% (99% confidence interval: 0.2% to 1.4%), i.e., too small to be of clinical or managerial importance. Neurosurgical cases may have been a significant predictor of work habits (P = 0.0054). However, the resulting marginal change in the percentage of work habits scores equal to the maximum, an increase of 0.8% (99% confidence interval: 0.1% to 1.6%), which was again too small to be important.
CONCLUSIONS: When evaluating the effect of assigning anesthesiologists and nurse anesthetists with different clinical performance quality on clinical outcomes, supervision quality and work habits scores may be included as independent variables without concern that their effects are confounded by association with the patient or case characteristics. Clinical supervision and work habits are measures of non-technical skills. Hence, these findings suggest that non-technical performance can be judged by observing the typical small sample size of cases. Then, associations can be tested with administrative data for a far greater number of patients because there is unlikely to be a confounding association between patient and case characteristics and the clinicians\' non-technical performance.
METHODS: Eight fiscal years of evaluations and surgical cases from one hospital were included. Clinical supervision by anesthesiologists was evaluated daily using a nine-item scale. Work habits of nurse anesthetists were evaluated daily using a six-item scale. The dependent variables for both groups of staff were binary, whether all items were given the maximum score or not. Associations were tested with patient and operational variables for the entire day.
RESULTS: There were 40,718 evaluations of faculty anesthesiologists by trainees, 53,772 evaluations of nurse anesthetists by anesthesiologists, and 296,449 cases that raters and ratees started together. Cohen\'s d values were small (≤0.10) for all independent variables, suggesting a lack of any clinically meaningful association between patient and operational factors and evaluations given the maximum scores. For supervision quality, the day\'s count of orthopedic cases was a significant predictor of scores (P = 0.0011). However, the resulting absolute marginal change in the percentage of supervision scores equal to the maximum was only 0.8% (99% confidence interval: 0.2% to 1.4%), i.e., too small to be of clinical or managerial importance. Neurosurgical cases may have been a significant predictor of work habits (P = 0.0054). However, the resulting marginal change in the percentage of work habits scores equal to the maximum, an increase of 0.8% (99% confidence interval: 0.1% to 1.6%), which was again too small to be important.
CONCLUSIONS: When evaluating the effect of assigning anesthesiologists and nurse anesthetists with different clinical performance quality on clinical outcomes, supervision quality and work habits scores may be included as independent variables without concern that their effects are confounded by association with the patient or case characteristics. Clinical supervision and work habits are measures of non-technical skills. Hence, these findings suggest that non-technical performance can be judged by observing the typical small sample size of cases. Then, associations can be tested with administrative data for a far greater number of patients because there is unlikely to be a confounding association between patient and case characteristics and the clinicians\' non-technical performance.
摘要：
背景：尽管安全气候，团队合作,手术室中的其他非技术技能可能会影响临床结果，没有显示直接关联，至少部分是由于样本量的考虑。我们报告了麻醉评估的回顾性队列数据，可以简化该领域前瞻性观察研究的设计。麻醉中的非技术技能之间的关联，特别是麻醉师“临床监督质量和护士麻醉师”的工作习惯，并检查了患者和手术因素。
方法：纳入了一家医院的八个财政年度评估和手术案例。每天使用九项量表评估麻醉医师的临床监督。每天使用六项量表评估护士麻醉师的工作习惯。两组员工的因变量都是二元的，是否所有项目都被给予最高分数。用一整天的患者和操作变量测试相关性。
结果：受训人员对麻醉师进行了40,718次评估，麻醉师对护士麻醉师的53,772次评估，和296,449起案件，评价者和费率一起开始。对于所有自变量，科恩的d值都很小(≤0.10)，提示患者和手术因素之间缺乏任何有临床意义的关联,并在评分最高的情况下进行评估.对于监理质量，骨科病例的日计数是评分的显著预测因子(P=0.0011).然而,由此产生的监督分数等于最大值的绝对边际变化百分比仅为0.8％（99％置信区间：0.2％至1.4％），即，太小，不具有临床或管理重要性。神经外科病例可能是工作习惯的重要预测指标（P=0.0054）。然而,由此产生的工作习惯分数百分比的边际变化等于最大值，增加0.8%(99%置信区间：0.1%至1.6%)，这又太小了，不重要。
结论：在评估分配不同临床表现质量的麻醉医师和麻醉护士对临床结果的影响时，监管质量和工作习惯评分可以作为自变量纳入,而不用担心其效果会与患者或病例特征相关.临床监督和工作习惯是衡量非技术技能的指标。因此，这些发现表明，可以通过观察典型的小样本病例来判断非技术表现。然后，可以使用更多患者的管理数据来测试相关性,因为患者和病例特征与临床医生的非技术表现之间不太可能存在混淆性关联.
方法：纳入了一家医院的八个财政年度评估和手术案例。每天使用九项量表评估麻醉医师的临床监督。每天使用六项量表评估护士麻醉师的工作习惯。两组员工的因变量都是二元的，是否所有项目都被给予最高分数。用一整天的患者和操作变量测试相关性。
结果：受训人员对麻醉师进行了40,718次评估，麻醉师对护士麻醉师的53,772次评估，和296,449起案件，评价者和费率一起开始。对于所有自变量，科恩的d值都很小(≤0.10)，提示患者和手术因素之间缺乏任何有临床意义的关联,并在评分最高的情况下进行评估.对于监理质量，骨科病例的日计数是评分的显著预测因子(P=0.0011).然而,由此产生的监督分数等于最大值的绝对边际变化百分比仅为0.8％（99％置信区间：0.2％至1.4％），即，太小，不具有临床或管理重要性。神经外科病例可能是工作习惯的重要预测指标（P=0.0054）。然而,由此产生的工作习惯分数百分比的边际变化等于最大值，增加0.8%(99%置信区间：0.1%至1.6%)，这又太小了，不重要。
结论：在评估分配不同临床表现质量的麻醉医师和麻醉护士对临床结果的影响时，监管质量和工作习惯评分可以作为自变量纳入,而不用担心其效果会与患者或病例特征相关.临床监督和工作习惯是衡量非技术技能的指标。因此，这些发现表明，可以通过观察典型的小样本病例来判断非技术表现。然后，可以使用更多患者的管理数据来测试相关性,因为患者和病例特征与临床医生的非技术表现之间不太可能存在混淆性关联.
