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July 2018 SEA-Q


Which of the following assessment tools is the BEST direct measure of Situational Awareness (SA) in anesthesia?

  • A.) Ottawa Global Rating Scale
  • B.) Anesthetic Non-Technical Skills (ANTS)
  • C.) Team Emergency Assessment Measure (TEAM)
  • D.) Situational Awareness Global Assessment Technique (SAGAT)


D.): Situational Awareness Global Assessment Technique (SAGAT)


Situational Awareness (SA) was first described by Endlsey in the 1980’s in the context of aviation.1 It is defined as “the perception of elements of the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future.” Hence, there are three hierarchical levels of SA: Level I Perception, Level II Comprehension, and Level III Projection. The application of SA in the field of anesthesia was then introduced by Gaba et al in 1995.2 Each level can be easily translated to the work of an anesthesiologist. For example, Level I being the collection of data when a patient becomes hypotensive, Level II being the comprehension of why the patient is hypotensive, while Level III is the integration of all those factors into creating a plan of how to manage the hypotension.
As decades of studies have revealed the importance of SA in crisis management and aviation, it naturally paved the way for the need to measure, understand and interpret SA in the field of healthcare and how it can be applied to improving patient safety. Although SA has been elaborated on to include team dynamics as well as other nonhuman subsystems, it is clear that subjects gain SA from a variety of sources and that greater SA can contribute to fewer perioperative complications.3 Thus far, both direct and indirect methods in measuring SA have been investigated. Direct tools measure SA itself, while indirect ones look SA through the measurement of other non-technical skills.
Team Emergency Assessment Measure (TEAM) is an observational rating scale designed to investigate non-technical skills during active resuscitation. It measures SA indirectly as it contains two of the three SA levels, perception and projection. The main caveat with this measure is that although it may have an overall high validity, the interrater reliability is lowest in the SA category.4 The Anesthetic Non-Technical Skills (ANTS) was designed and validated for the assessment of anesthetic nontechnical skills through the measurement of four subcategories, one of which is SA, while the others are task management, team working, and decision making.5 As with TEAM, the interrater reliability is lowest in the SA category, illustrating that there are difficulties in understanding and evaluating SA. The Ottawa Global Rating was created to assess nonmedical skills in Crisis Response Management (CRM). The five sections the scale evaluates are based on Gaba’s key aspects for effective CRM: leadership, problem solving, SA, communication skills, and resource management.6 Although the interrater validity here was not lowest for SA, the scale does not specifically assess SA and is therefore indirect.
In order to directly asses SA, the Situational Awareness Rating Technique (SAGAT) was designed. This tool uses scenario specific questionnaires which require stopping at random times in order to perform the assessment. Questions are specifically created based on any given scenario in order to assess perception, comprehension, and projection. Although some have argued that interrupting a scenario might affect performance, others have confirmed that this is negligible.3 As the SAGAT is not based on observer ratings of SA but instead on a predetermined set of questions that are either scored as correct or incorrect, the SAGAT is more objective and offers greater validity and reliability.4


  1. Endsley, MR. "Design and evaluation for situation awareness enhancement." In Proceedings of the Human Factors Society annual meeting, vol. 32, no. 2, pp. 97-101. Sage CA: Los Angeles, CA: SAGE Publications, 1988.
  2. Gaba, DM., Steven K. Howard, and Stephen D. Small. "Situation awareness in anesthesiology." Human Factors 37, no. 1 (1995): 20-31.
  3. Schulz, Christian M., Mica R. Endsley, Eberhard F. Kochs, Adrian W. Gelb, and Klaus J. Wagner. "Situation Awareness in AnesthesiaConcept and Research." Anesthesiology: The Journal of the American Society of Anesthesiologists 118, no. 3 (2013): 729-742.
  4. Cooper, Simon, Joanne Porter, and Linda Peach. "Measuring situation awareness in emergency settings: a systematic review of tools and outcomes." Open access emergency medicine: OAEM 6 (2014): 1.
  5. Flin, Rhona, Rona Patey, Ronnie Glavin, and Nikki Maran. "Anaesthetists’ non-technical skills." British journal of anaesthesia 105, no. 1 (2010): 38-44.
  6. Kim, John, David Neilipovitz, Pierre Cardinal, Michelle Chiu, and Jennifer Clinch. "A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management I Study." Crit Care Med 34, no. 8 (2006): 2167-2174.

Author Information:

Michal Gajewski, DO
Assistant Professor
Residency Program Director
Director, Trauma Anesthesiology
Department of Anesthesiology
New Jersey Medical School
Rutgers, The State University of New Jersey


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Contact Info:

Society for Education in Anesthesia
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