Objective To develop a comprehensive checklist, define critical actions, and establish a minimal passing standard for adult and pediatric critical care clinicians as well as other providers to facilitate formative and summative assessment of brain death/death by neurologic criteria (BD/DNC) determination Design: A pre-specified three round modified Delphi consensus process to define checklist items followed by a modified Angoff standard setting process to determine critical actions and item average ratings.

Setting Electronic surveys.

Subjects Selected authors of the 2023 Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline, World Brain Death Project, and experts recommended by these authors (n=16) participated in the Delphi panel. Neurocritical care United Council for Neurologic Subspecialties and Accreditation Council for Graduate Medical Education examination committee members (n= 13) participated in Angoff standard setting.

Measurements and Main Results A total of 98 unique checklist items related to assessment of prerequisites (23 items), performance of the clinical examination (28 items), apnea testing (36 items), and ancillary testing (11 items) were retained by the Delphi panel. Seven items were designated as critical actions based upon Angoff panelist consensus. The remaining 91 items were assigned item average ratings. The minimum passing score for an assessment including all items was set at 89%.

Conclusions These guideline-concordant consensus checklist items, including critical actions and non-critical actions with their assigned item average ratings, may be applied selectively to simulated cases of BD/DNC determination for adults and children to determine a minimum passing score and readiness for independent practice, mitigating risk of inaccurate BD/DNC determination among critical care clinicians. Our process for systematically defining critical actions on a behavior checklist may be replicated for simulation-based summative assessment of learners in other critical care scenarios.

Question What behaviors should be included in a checklist for assessment of brain death/death by neurologic criteria (BD/DNC) determination and what level of performance is consistent with readiness for independent practice?

Findings A modified Delphi panel identified 98 checklist items which may be applied selectively to simulated cases of BD/DNC. An Angoff panel identified 7 critical actions and set average ratings for all other items.

Meaning These guideline-concordant consensus checklist items and their average ratings may be applied to assessments of simulated or real cases of BD/DNC, including those intended for summative assessment, to determine learner readiness for independent determination.

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: NAM has received research funding from the American Academy of Neurology; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

This study was funded by the American Academy of Neurology Education Research Award.

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The IRB of Boston University waived ethical approval for this work.

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Simulation-based mastery learning to assess and Ensure COmpetency in death by Neurologic criteria Determination (SECOND) Study Group Members: Ariane Lewis, Lori Shutter, Michael A. Rubin, Panayiotis N. Varelas, Katharina M. Busl, Matthew P. Kirschen, Thomas A. Nakagawa, Paul Vespa, Cherylee W.J. Chang, David F. Bauer, Carolina Barbosa Maciel, Michael Souter, Fernando D. Goldenberg, Conall Francoeur, Thomas P. Bleck, Gene Sung, Sarah E. Nelson, Lauren Koffman, Evadne G. Marcolini, Samuel Galvagno, Christa Nobleza, Brenda Fahy, Ivan Da Silva, Alejandro A. Rabinstein, Abhay Kumar, Jordan Bonomo, Claude Hemphill, Rahul Nanchal, Bradley Dengler

All data produced in the present study are available upon reasonable request to the authors.