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In 2018, the American Society of Anesthesiologists stated that student registered nurse anesthetists (SRNAs) “are not yet fully qualified anesthesia personnel.” It remains unclear, however, whether postprocedural outcomes are affected by SRNAs providing anesthesia care under the medical direction of anesthesiologists, as compared with medically directed anesthesiology fellows or residents, or certified registered nurse anesthetists (CRNAs). We therefore aimed to examine whether medically directed SRNAs serving as in-room anesthesia providers impact surgical outcomes. Retrospective, matched-cohort analysis. Adult patients (≥18 years old) undergoing inpatient surgery between 2000 and 2017 at a tertiary academic medical center. 15,365 patients exclusively cared for by medically directed SRNAs were matched to 15,365 cared for by medically directed CRNAs, anesthesiology residents, and/or fellows. None. The primary composite outcome was postoperative occurrence of in-hospital mortality and six categories of major morbidities (infectious, bleeding, serious cardiac, gastrointestinal, respiratory, and urinary complications). In-hospital mortality was analyzed as the secondary outcome. In all, 30,730 cases were matched using propensity score matching to control for potential confounding. The primary outcome was identified in 2295 (7.5%) cases (7.5% with exclusive medically directed SRNAs vs 7.4% with medically directed CRNAs, residents and/or fellows; relative risk, 1.02; 95% CI, 0.94–1.11). Thus, our effort to determine noninferiority (10% difference in relative risk) with other providers was inconclusive (P = .07). However, the medically directed SRNA group (0.8% [118]) was found to be noninferior (P < .001) to the matched group (1.0% [156]) on in-hospital mortality (relative risk, 0.75; 95% CI, 0.59–0.96). Among 30,730 patients undergoing inpatient surgery at a single hospital, findings were inconclusive regarding whether exclusive medically directed SRNAs as in-room providers were noninferior to other providers. The use of medically directed SRNAs under this staffing model should be subject to further review. Clinical Trial and Registry URL: Not applicable. •The noninferiority of exclusive medically directed SRNA as in-room providers on primary composite outcome was inconclusive.•Exclusive medically directed SRNAs serving as the in-room provider was found to be noninferior for in-hospital mortality.•The analysis of medically directed SRNA group and sensitivity analysis on NSQIP defined outcomes revealed similar results.•Additional research is warranted regarding the role of medically directed SRNAs under different anesthesia staffing models.

Background Non-technical skills are the essential cognitive, social, and personal resources contributing to safe and efficient task performance. An assessment tool can facilitate the development and teaching of non-technical skills. The nurse anesthetist non-technical skills tool includes four categories and fifteen elements and is an adaptation of the existing tools for physician anesthetists and Danish nurse anesthetists. The ratings are on a five-step scale, with an option to select “Not Relevant”. Since there doesn’t exist an assessment tool for Swedish nurse anesthetists’ non-technical skills, the aim of the study was to translate and adapt the assessment tool for nurse anesthetists’ non-technical skills to a Swedish context and test its psychometric qualities among nurse anesthetists with experience in teaching nurse anesthetist students and junior nurse anesthetists in clinical settings. Methods In this prospective psychometric evaluation study, sixteen nurse anesthetists were recruited. They rated 12 video clips of simulated anesthesia scenarios after participating in a three-hour calibration workshop. Four weeks later, a test–retest was conducted, which included five video clips. Internal consistency, Interrater reliability, and test–retest reliability were examined. Results Internal consistency showed acceptable results on the element level and Interrater reliability indicated good results. Retest reliability showed poor to moderate reliability. The use of “Not Relevant” varied significantly depending on the length of the video clip and the provider being rated. The raters considered the assessment tool suitable but initially challenging to use for rating non-technical skills among nurse anesthetists and articulate non-technical skills in anesthesia nursing. Conclusions This initial testing of the Swedish nurse anesthetists’ non-technical skills tool shows acceptable psychometric qualities and gives a foundation for future research. However, the rating “Not Relevant” poses challenges that need to be addressed. Nevertheless, the participants consider the assessment of non-technical skills in Swedish nurse anesthetists to be appropriate.

Certified registered nurse anesthetists (CRNAs) can evaluate anesthesiologists with whom they work clinically using a psychometrically reliable and valid scale. Use of such a scale to evaluate performance depends on knowing thresholds for minimum and ideal anesthesiologist performance. Cohort study. One large teaching hospital. 379 CRNA evaluations of anesthesiologists' performance, and associated thresholds for minimum and ideal scores, performed over 15 weeks. The anesthesiologists' performance score was less than the CRNA's minimum score for the evaluation (i.e., too little anesthesiologist participation in patient care) for 25% (95) of the CRNA evaluations. The score was greater than the CRNA's ideal score for the evaluation (i.e., excessive participation in patient care) for 28% (106) of evaluations. Anesthesiologists' performance was assessed as not meeting expectations 53% of the time. Even if every anesthesiologist performed consistently at the same level, ≥50% of CRNAs would have been dissatisfied (187), not significantly different from observed (P = 0.34). Consistent results were found when the unit of analysis was individual CRNA. Among the 22 CRNAs who provided ≥10 evaluations, the median level of anesthesiologist performance was either less than the individual CRNA's mean minimum acceptable performance (8/22) or greater than their mean ideal performance (9/22), with overall dissatisfaction, 77%. Among the CRNA-anesthesiologist pairs working together, most did so less than once per month (76%, 1242/1635). In this single-center study at a large teaching hospital, broad heterogeneity among CRNAs in their expectations for anesthesiologist collaborative practice was found. Anesthesiologists adjusting their behavior based on individual CRNA preferences was impractical because specific CRNA-anesthesiologist pairs work together infrequently. Future studies should examine consistency among organizations and whether changes in expectations, and perhaps less dissatisfaction, can be achieved by communication of results for CRNA preferences for anesthesiologists' participation in patient care and discussing shared expectations among the CRNAs and anesthesiologists. •During evaluation of anesthesiologists’ performance, nurse anesthetists judged too little participation in patient care for 1/4 evaluations.•During evaluation of anesthesiologists’ performance, nurse anesthetists judged excessive participation in patient care for 1/4 of evaluations.•No systematic change in anesthesiologists’ performance department wide could reduce the 50% dissatisfaction.

Proficiency in epidural placement remains a challenging skill for anesthesia providers, requiring the ability to discern loss of resistance (LOR) when entering the epidural space. Current educational manikins lack the tactile feedback required for realistic epidural training. This descriptive pilot study aimed to compare an porcine spine model with the M43B manikin model for simulation of clinical epidural placement. Expert anesthesia providers (n = 10) evaluated physical characteristics of each model using a survey comprised of a visual analog scale (0-100) and qualitative open-ended questions. Continuous data were analyzed using paired two-tailed Student's t tests, while qualitative open-ended narrative responses were reported by response frequency. Epidural simulation with the porcine spine demonstrated significantly higher clinical similarity scores ( < .001) for ligamentum flavum feel (85 ± 4.5 vs. 32 ± 8.1), LOR (93.5 ± 3.0 vs. 42.5 ± 10.7), catheter insertion (92.3 ± 3.9 vs. 48.8 ± 8.0), and novice training utility (92.5 ± 3.3 vs. 41.5 ± 7.7), while landmark identification (iliac crest/spinous processes) was comparable between models. Providers unanimously preferred the porcine model for epidural simulation. Simulation using an porcine spine model enhances the realism of epidural training and underscores the importance of utilizing clinically relevant models for anesthesia procedural skill acquisition and maintenance.

Anesthesiologists can provide psychometrically reliable daily evaluations of certified registered nurse anesthetist (CRNA) work habits for purposes of the mandatory ongoing professional practice evaluation (OPPE). Our goal was to evaluate the validity of assessing CRNA work habits. Observational study. Large teaching hospital. N=77 anesthesiologists evaluated work habits of N=67 CRNAs. The non-technical attribute of work habits was measured on a 6-item scale (e.g., 1=“Only assumed responsibility when forced to, and failed to follow through consistently” versus 5=“Consistently identified tasks and completed them efficiently and thoroughly”). One year of scores were used to assess validity. Each daily evaluation could also be accompanied by a written comment. Content analysis of comments was performed using two years of data. Statistical analyses were performed using mixed effects logistic regression, treating each anesthesiologist as a fixed effect to compensate for the leniency of their ratings. The N=77 anesthesiologists' response rate was 97.3%, obtained at a mean 2.93days after the request. The internal consistency of the scale was large: Cronbach's alpha 0.952. Controlling the false discovery rate at 5.0%, among the 67 CRNAs, 8 were significantly below average (each P≤0.0048) and 6 were above average (each P≤0.0018). During the 6months after CRNAs knew that their work habits scores would be used for OPPE, there were significant increases in the scores compared with the preceding 6months (odds ratio 1.93, P<0.0001). Greater CRNA's qualitative annual evaluation scores made by the chief CRNA, without knowledge of the work habit scores or comments, were associated with greater odds of the CRNA's leniency-adjusted work habit scores equaling 5.00 (odds ratio 1.53, P=0.0004). Comments of negative sentiment made by the anesthesiologists were associated with greater odds of the leniency-adjusted work habit scores being <5.00 (odds ratio 54.5, P<0.0001). Even though the anesthesiologists were already providing information about work habits using the work habits scale, approximately half the comments of negative sentiment included the theme of work habits (92/153, 60.1%). Reporting OPPE metrics are mandatory for the maintenance of clinical privileges of anesthesia practitioners in the USA. Basing such peer review on work habits can be quantitative, psychometrically reliable, and valid. •Peer review of certified registered nurse anesthetists should be quantitative, psychometrically reliable, and valid.•Work habits were measured on a 6 item scale.•Greater annual evaluation scores were associated with higher work habits scores.•Comments with negative sentiment were associated with lower work habit scores.•Comments with negative sentiment often included the theme of work habits.•Results show validity of using a work habits scale for daily evaluation of nurse anesthetists' clinical performance.

Background Performing CPR (Cardiopulmonary Resuscitation) is an extremely intricate skill whose success depends largely on the level of knowledge and skill of Anesthesiology students. Therefore, this research was conducted to compare the effect of the scenario-based training method as opposed to video training method on nurse anesthesia students’ BLS (Basic Life Support) knowledge and skills. Methods This randomized quasi-experimental study involved 45 nurse anesthesia students of Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran in 2022–2023. The practical room of the university formed the research environment. The participants were randomly divided into three groups of scenario-based training, video training, and control. Data were collected by a knowledge questionnaire and a BLS skill assessment checklist before and after the intervention. Results There was a significant difference between the students’ scores of BLS knowledge and skill before and after the educational intervention in both SG (scenario group) ( p  < 0.001) and VG (video group) ( p  = 0.008) ( p  < 0.001). However, no significant difference was observed in this regard in the CG (control group) ( p  = 0.37) ( p  = 0.16). Also, the mean scores of BLS knowledge and skills in the SG were higher than those in the VG ( p  < 0.001). Conclusion Given the beneficial impact of scenario-based education on fostering active participation, critical thinking, utilization of intellectual abilities, and learner creativity, it appears that this approach holds an advantage over video training, particularly when it comes to teaching crucial subjects like Basic Life Support.

Simulation is a valuable tool for developing technical skills and self-efficacy for high-risk, low-frequency events such as cannot intubate, cannot oxygenate (CICO) scenario. There is a deficiency of evidence regarding CICO events and emergency front of neck access training for resident registered nurse anesthetists (RRNAs). This study explored whether a low-fidelity simulation training utilizing a 3D-printed cricothyrotomy task trainer and educational intervention increased self-efficacy, improved performance measures (performance time, performance checklist scores), and increased expert performance levels (performance time, performance checklist score, completion of critical performance checklist steps) regarding scalpel-bougie-tube surgical cricothyrotomy (SBT-SC) among RRNAs. This pilot study utilized a quasiexperimental pretest-posttest design. Ten RRNAs participated in the study. Statistical analysis with paired t-tests demonstrated statistically significant improvement in mean self-efficacy scores (3.13 to 4.5 out of 5, < .001), mean performance completion time (103.5 seconds (SD, 34.5) to 55.9 (SD, 17.9) seconds [ < .001]), mean performance checklist scores (5.5 to 9.1 out of 10, [ < .001]), and completion of critical checklist steps. Six participants completed the postintervention SBT-SC in under 60 seconds while completing all critical checklist steps. One participant met expert performance benchmark criteria following the intervention. This study supports low-fidelity simulation for SBT-SC education and training for RRNAs.

Background Several Japanese educational institutions have begun to train nurse anesthetists. They manage the patient consistently from pre-operation to post-operation in collaboration with the anesthesiologist. This has helped improve the quality of anesthetic management in an anesthesiologist shortage environment in Japan. However, no studies have examined the quality of anesthetic management by nurses worldwide. Therefore, this study investigated the quality of anesthesia among novice anesthesiology residents and nurse anesthetists, focusing on blood pressure control. Methods This study included adult patients undergoing breast surgery. Nurse anesthetists or anesthesiology residents oversaw general anesthesia. Intraoperative electronic medical records were used to compare the general anesthesia management of nurses and residents. The primary outcome was the sum of the duration during which the mean blood pressure was < 65 mmHg. This was quantified as a percentage of the total anesthesia time (time under mean 65 mmHg: TUm65). Independent variables included patient demographic characteristics, clinical information, the percentage decrease from baseline in the lowest mean blood pressure during anesthesia, and the hourly infusion volume. Results No significant difference was observed in the TUm65 (nurse anesthetists vs. anesthesiology residents: median [IQR] 11.3% [3.3–20.7] vs. 18.1% [5.3–24.0], p  = 0.078). No significant differences were noted between nurses and residents concerning the other outcomes. Conclusion No significant differences were observed in the intraoperative blood pressure control between the nurse anesthetists and anesthesia residents.

Despite the fact that anesthesia was discovered in the United States, we believe that both physicians and nurses are largely unaware of many aspects of the development of the nurse anesthetist profession. A shortage of suitable anesthetists and the reluctance of physicians to provide anesthetics in the second half of the 19th century encouraged nurses to take on this role. We trace the origins of the nurse anesthetist profession and provide biographical information about its pioneers, including Catherine Lawrence, Sister Mary Bernard Sheridan, Alice Magaw, Agatha Cobourg Hodgins, and Helen Lamb. We comment on the role of the nuns and the effect of the support and encouragement of senior surgeons on the development of the specialty. We note the major effect of World Wars I and II on the training and recruitment of nurse anesthetists. We provide information on difficulties faced by nurse anesthetists and how these were overcome. Next, we examine how members of the profession organized, developed training programs, and formalized credentialing and licensing procedures. We conclude by examining the current state of nurse anesthesia practice in the United States. •Origins of the nurse anesthetist profession are investigated.•Careers of pioneer nurse anesthetists are explored.•Organization, training, and certification of nurse anesthetists are described.

Olive Berger was a true nurse anesthesia pioneer for our profession. She dedicated her life to the advancement of nurse anesthesia through her leadership, advocacy, scholarly writing, clinical achievements and innovation. She blazed the trail by forming and establishing education requirements for nurse anesthesia programs, established a state nurse anesthesia organization, and led the American Association of Nurse Anesthetists as its 14th president in 1958. She was the Chief Certified Registered Nurse Anesthetist and Program Director at the Johns Hopkins Hospital and is best known for her collaboration with surgeons Dr. Alfred Blalock and Dr. Helen Taussig, providing anesthesia care during the groundbreaking repair of tetralogy of Fallot on infants.