Academic Appointments

Administrative Appointments

  • Chair, Clinical Competence Committee, Department of Anesthesia (2011 - Present)
  • Member, Resident Education Committee, Department of Anesthesia (1993 - Present)
  • Member, Resident Selection Committee, Department of Anesthesia (1997 - Present)

Boards, Advisory Committees, Professional Organizations

  • Member, Educational Track Subcommittee on Professional Issues, American Society of Anesthesiologists (2008 - Present)
  • Member, Professional Advisory Committee, Malignant Hyperthermia Association of the United States (2009 - Present)
  • Member, Editorial Board, Anesthesiology Research and Practice (2010 - Present)
  • Member, Editorial Board, Simulation in Healthcare (2011 - Present)
  • Member, Abstract Review Committee on Patient Safety and Practice Management, American Society of Anesthesiologists (2012 - Present)
  • Chairperson, Scientific Evaluation Committee, Anesthesia Patient Safety Foundation (2013 - Present)
  • 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)

Research & Scholarship

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).


2015-16 Courses


All Publications

  • 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 Web of Science ID 000357281100027

  • 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

  • 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

  • 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 Web of Science ID 000348887900017

  • 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

  • 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 Web of Science ID 000346240300009

  • 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 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 Web of Science ID 000341405300018

    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 Web of Science ID 000334180400008

  • 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 Web of Science ID 000330435700018

  • 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

  • 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 Web of Science ID 000261970100016

    View details for PubMedID 19114195

  • Trauma training in simulation: Translating skills from SIM time to real time JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE Knudson, M. M., Khaw, L., Bullard, M. K., Dicker, R., Cohen, M. J., Staudenmayer, K., Sadjadi, J., Howard, S., Gaba, D., Krummel, T. 2008; 64 (2): 255-263


    : 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

  • So many roads: Faciltiated debriefing in healthcare Simulation in Healthcare Dismukes, R., Gaba DM, Howard SK 2006; 1 (1): 23-25
  • 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
  • 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

  • Measuring sleep onset: Comparing the standard versus an experimental montage Howard, S. K., Smith-Coggins, R., Nevarez, M., Sohoni, A., Gaba, D., Rosekind, M. AMER ACAD SLEEP MEDICINE. 2005: A324-A325
  • Sleep propensity and performance: Evaluating a brief protocol in health care providers Howard, S. K., Smith-Coggins, R., Nevarez, M., Sohoni, A., Gaba, D., Rosekind, M. AMER ACAD SLEEP MEDICINE. 2005: A133-A133
  • 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 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

  • 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

  • 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

  • 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 Web of Science ID 000089623100002

    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

  • 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: 767-768
  • 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: 766-767
  • 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
  • Assessment of clinical performance during simulated crises using both technical and behavioral ratings ANESTHESIOLOGY Gaba, D. M., Howard, S. K., Flanagan, B., Smith, B. E., Fish, K. J., Botney, R. 1998; 89 (1): 8-18


    Techniques are needed to assess anesthesiologists' performance when responding to critical events. Patient simulators allow presentation of similar crisis situations to different clinicians. This study evaluated ratings of performance, and the interrater variability of the ratings, made by multiple independent observers viewing videotapes of simulated crises.Raters scored the videotapes of 14 different teams that were managing two scenarios: malignant hyperthermia (MH) and cardiac arrest. Technical performance and crisis management behaviors were rated. Technical ratings could range from 0.0 to 1.0 based on scenario-specific checklists of appropriate actions. Ratings of 12 crisis management behaviors were made using a five-point ordinal scale. Several statistical assessments of interrater variability were applied.Technical ratings were high for most teams in both scenarios (0.78 +/- 0.08 for MH, 0.83 +/- 0.06 for cardiac arrest). Ratings of crisis management behavior varied, with some teams rated as minimally acceptable or poor (28% for MH, 14% for cardiac arrest). The agreement between raters was fair to excellent, depending on the item rated and the statistical test used.Both technical and behavioral performance can be assessed from videotapes of simulations. The behavioral rating system can be improved; one particular difficulty was aggregating a single rating for a behavior that fluctuated over time. These performance assessment tools might be useful for educational research or for tracking a resident's progress. The rating system needs more refinement before it can be used to assess clinical competence for residency graduation or board certification.

    View details for Web of Science ID 000074710800004

    View details for PubMedID 9667288

  • 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: 513-514
  • 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

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