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Assessment of central venous catheterization in a simulated model using a motion-tracking device: an experimental validation study. - Annals of surgical innovation and research
Central venous catheterization (CVC) is a basic requirement for many medical specialties. Simulated training in CVC may allow the acquisition of this competency but few reports have established a valid methodology for learning and acquiring procedural skills for CVC. This study aims to validate the use of a tracking motion device, the imperial college surgical assessment device (ICSAD), by comparing it with validated global rating scales (GRS) to measure CVC performance in a simulated torso.Senior year medical students, first and last year residents (PGY1, LYR), and expert anesthesiologists performed a jugular CVC assessment in a simulated model (Laerdal IV Torso). A validated GRS for objective assessment of technical skills and motion analysis by ICSAD was used. Statistical analysis was performed through Mann-Whitney and Kruskal-Wallis tests for construct validity and Spearman correlation coefficients between the ICSAD and GRS scores for concurrent validity between both.32 subjects were recruited (10 medical students, 8 PGY1, 8 LYR and 8 experts). Total path length measured with ICSAD and GRS scores were significantly different between all groups, except for LYR compared to experts (pÂ =Â 0.664 for GRS and pÂ =Â 0.72 for ICSAD). Regarding jugular CVC procedural time, LYR and experts were faster than PGY1 and MS (pÂ <Â 0.05). Spearman correlation coefficient was -0.684 (pÂ <Â 0.001) between ICSAD and GRS scores.ICSAD is a valid tool for assessment of jugular CVC since it differentiates between expert and novice subjects, and correlates with a validated GRS for jugular CVC in a simulated torso.
Putting the MeaT into TeaM Training: Development, Delivery, and Evaluation of a Surgical Team-Training Workshop. - Journal of surgical education
Despite importance to patient care, team training is infrequently used in surgical education. To address this, a workshop was developed by the Association for Surgical Education Simulation Committee to teach team training using high-fidelity patient simulators and the American College of Surgeons-Association of Program Directors in Surgery team-training curriculum.Workshops were conducted at 3 national meetings. Participants completed preworkshop and postworkshop questionnaires to define experience, confidence in using simulation, intention to implement, as well as workshop content quality. The course consisted of (A) a didactic review of Preparation, Implementation, and Debriefing and (B) facilitated small group simulation sessions followed by debriefings.Of 78 participants, 51 completed the workshops. Overall, 65% indicated that residents at their institutions used patient simulation, but only 33% used the American College of Surgeons-the Association of Program Directors in Surgery team-training modules. The workshop increased confidence to implement simulation team training (3.4 Â± 1.3 vs 4.5 Â± 0.9). Quality and importance were rated highly (5.4 Â± 00.6, highest score = 6).Preparation for simulation-based team training is possible in this workshop setting, although the effect on actual implementation remains to be determined.Copyright Â© 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Early targeted brain COOLing in the cardiac CATHeterisation laboratory following cardiac arrest (COOLCATH). - Resuscitation
Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill, an intranasal cooling device over Blanketrol, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory.70 patients were randomized to TH induction with either Rhinochill or Blanketrol. Primary outcome measures were time to reach tympanic â‰¤34 Â°C from randomisation as a surrogate for brain temperature and oesophageal â‰¤34 Â°C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge.There was no difference in time to reach â‰¤34 Â°C between Rhinochill and Blanketrol (Tympanic â‰¤34 Â°C, 75 vs. 107 mins; p=0.101; Oesophageal â‰¤34 Â°C, 85 vs. 115 mins; p=0.151). Tympanic temperature dropped significantly with Rhinochill in the first hour (1.75 vs. 0.94 Â°C; p<0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%.In this study, Rhinochill was not found to be more efficient than Blanketrol for TH induction, although there was a non-significant trend in favour of Rhinochill that potentially warrants further investigation with a larger trial.Copyright Â© 2015 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.
An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains. - American journal of surgery
Key research priorities for surgical simulation have been identified in recent years. The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved.Members of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel.Excellent progress has been made in the assessment of individual and teamwork skills in simulation. The best methods of feedback and debriefing have not yet been established. Progress in answering more complex questions related to competence and transfer of training is slower than other questions. A link between simulation training and patient outcomes remains elusive.Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery. The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come.Copyright Â© 2016 Elsevier Inc. All rights reserved.
Expert Intraoperative Judgment and Decision-Making: Defining the Cognitive Competencies for Safe Laparoscopic Cholecystectomy. - Journal of the American College of Surgeons
Bile duct injuries from laparoscopic cholecystectomy remain a significant source of morbidity and are often the result of intraoperative errors in perception, judgment, and decision-making. This qualitative study aimed to define and characterize higher-order cognitive competencies required to safely perform a laparoscopic cholecystectomy.Hierarchical and cognitive task analyses for establishing a critical view of safety during laparoscopic cholecystectomy were performed using qualitative methods to map the thoughts and practices that characterize expert performance. Experts with more than 5 years of experience, and who have performed at least 100 laparoscopic cholecystectomies, participated in semi-structured interviews and field observations. Verbal data were transcribed verbatim, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 2 independent reviewers, and synthesized into a list of items.A conceptual framework was created based on 10 interviews with experts, 9 procedures, and 18 literary sources. Experts included 6 minimally invasive surgeons, 2 hepato-pancreatico-biliary surgeons, and 2 acute care general surgeons (median years in practice, 11 [range 8 to 14]). One hundred eight cognitive elements (35 [32%] related to situation awareness, 47 [44%] involving decision-making, and 26 [24%] action-oriented subtasks) and 75 potential errors were identified and categorized into 6 general themes and 14 procedural tasks. Of the 75 potential errors, root causes were mapped to errors in situation awareness (24 [32%]), decision-making (49 [65%]), or either one (61 [81%]).This study defines the competencies that are essential to establishing a critical view of safety and avoiding bile duct injuries during laparoscopic cholecystectomy. This framework may serve as the basis for instructional design, assessment tools, and quality-control metrics to prevent injuries and promote a culture of patient safety.Copyright Â© 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Development of a PROficiency-Based StePwise Endovascular Curricular Training (PROSPECT) Program. - Journal of surgical education
Focus on patient safety, work-hour limitations, and cost-effective education is putting pressure to improve curricula to acquire minimally invasive techniques during surgical training. This study aimed to design a structured training program for endovascular skills and validate its assessment methods.A PROficiency-based StePwise Endovascular Curricular Training (PROSPECT) program was developed, consisting of e-learning and hands-on simulation modules, focusing on iliac and superficial femoral artery atherosclerotic disease. Construct validity was investigated. Performances were assessed using multiple-choice questionnaires, valid simulation parameters, global rating scorings, and examiner checklists. Feasibility was assessed by passage of 2 final-year medical students through this PROSPECT program.Ghent University Hospital, a tertiary clinical care and academic center in Belgium with general surgery residency program.Senior-year medical students were recruited at Ghent University Hospital. Vascular surgeons were invited to participate during conferences and meetings if they had performed at least 100 endovascular procedures as the primary operator during the last 2 years.Overall, 29 medical students and 20 vascular surgeons participated. Vascular surgeons obtained higher multiple-choice questionnaire scores (median: 24.5-22.0 vs. 15.0-12.0; p < 0.001). Students took significantly longer to treat any iliac or femoral artery stenosis (3.3-14.8 vs. 5.8-30.1min; p = 0.001-0.04), whereas in more complex cases, fluoroscopy time was significantly higher in students (8.3 vs. 21.3min; p = 0.002; 7.3 vs. 13.1min; p = 0.03). In all cases, vascular surgeons scored higher on global rating scorings (51.0-42.0 vs. 29.5-18.0; p < 0.001) and examiner checklist (81.5-75.0 vs. 54.5-43.0; p < 0.001). Hence, proficiency levels based on median expert scores could be determined. There were 2 students who completed the program and passed for each step within a 3-month period during their internships.A feasible and construct validated surgical program to train cognitive, technical, and nontechnical endovascular skills was developed. A structured, stepwise, proficiency-based valid endovascular program to train cognitive, technical, and human factor skills has been developed and proven to be feasible. A randomized controlled trial has been initiated to investigate its effect on performances in real life, patient outcomes, and cost-effectiveness.Copyright Â© 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Objective assessment of robotic surgical skill using instrument contact vibrations. - Surgical endoscopy
Surgical skill evaluation ordinarily requires tedious video review and survey completion, while new automatic approaches focus on evaluating the quality of the surgeon's movements in free space. Robotic surgical instrument vibrations are simple to measure and physically correspond to how roughly instruments are handled, but they have yet to be studied as a measure of technical surgical skill.Thirteen surgeons used a robotic surgery system (da Vinci S by Intuitive Surgical) to perform four trials each of peg transfer (PT), needle pass (NP), and intracorporeal suturing (IS). Completion time, instrument vibrations, and applied forces were measured for each trial; root mean square (RMS) and total sum of squares (TSS) were calculated from both the vibration and force recordings. Four experienced surgeons blindly assessed the task videos using a Global Rating Scale (GRS), and skill metrics were compared between the eight novices and five experienced participants. Stepwise regression was performed to predict GRS score from objective skill metrics. The concurrent validity of each metric was evaluated using receiver operating characteristic (ROC) analysis.The GRS demonstrated excellent internal consistency (Cronbach's Î±Â =Â 0.91) and strong inter-rater reliability (ICCÂ =Â 0.84). Compared to novices, experienced surgeons earned higher GRS scores and performed tasks with lower vibration magnitudes, lower forces, and shorter completion times in 15 of 18 task-metric combinations (p values ranging from 0.042 to <0.001). ROC analysis demonstrated that including vibration and force magnitudes along with completion time in skill prediction models improves the objective classification of subjects as novice or experienced for all tasks studied (PT: 90Â % sensitivity, 75Â % specificity; NP: 85Â % sensitivity, 84Â % specificity; suturing: 100Â % sensitivity, 100Â % specificity).RMS and TSS instrument vibrations are novel construct-valid measures of robotic surgical skill that enable the development of objective skill assessment models comparable to observer-based ratings.
A Randomized Controlled Trial to Assess the Effects of Competition on the Development of Laparoscopic Surgical Skills. - Journal of surgical education
Serious games have demonstrated efficacy in improving participation in surgical training activities, but studies have not yet demonstrated the effect of serious gaming on performance. This study investigated whether competitive training (CT) affects laparoscopic surgical performance.A total of 20 novices were recruited, and 18 (2 dropouts) were randomized into control or CT groups to perform 10 virtual reality laparoscopic cholecystectomies (LCs). Competitiveness of each participant was assessed. The CT group members were informed they were competing to outperform one another for a prize; performance ranking was shown before each session. The control group did not compete. Performance was assessed on time, movements, and instrument path length. Quality of performance was assessed with a global rating scale score.There were no significant intergroup differences in baseline skill or measured competitiveness. Time and global rating scale score, at final LC, were not significantly different between groups; however, the CT group was significantly more dexterous than control and had significantly lower variance in number of movements and instrument path length at the final LC (p = 0.019). Contentiousness was inversely related to time in the CT group.This was the first randomized controlled trial to investigate if CT can enhance performance in laparoscopic surgery. CT may lead to improved dexterity in laparoscopic surgery but yields otherwise similar performance to that of standard training in novices. Competition may have different effects on novices vs experienced surgeons, and subsequent research should investigate CT in experienced surgeons as well.Copyright Â© 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Effectiveness of learning advanced laparoscopic skills in a brief intensive laparoscopy training program. - Journal of surgical education
Intensive training programs arose from limitations in access to simulation centers. The aim of this study is to evaluate the effect and associated factors involved in an intensive course for learning advanced laparoscopic skills, which include validated teaching techniques.General surgeons and final-year residents were analyzed after completing an intensive 5-session advanced laparoscopy course. Initial (IA) and final assessment (FA) consisted in performing a jejunojejunal anastomosis in a live porcine model, measured using objective structured assessment of technical skill (OSATS) (GRS and SRS, that is, global rating scale and specific rating scale, respectively) and operative time (OT). The 3-session training was structured in a bench model with an ex vivo bowel. For the demographic analysis, 3 groups were defined according to the presentation of relevant changes in OSATS and in OT between IA and FA: group A, no changes; group B, change in 1 variable; and group C, change in both variables.After the course, all 114 participants presented a significant improvement in OT (37 vs 24.6min, p < 0.001) and in OSATS; global rating scale (10.5 vs 16 points; p < 0.001) and Specific Rating Scale (8.5 vs 12.7 points; p < 0.001). In the IA, 70 (61%) participants completed the jejunojejunal anastomosis and 105(92%) in the FA (p < 0.01). In the FA, 56% of participants presented relevant changes in both variables (group C). This group was significantly younger (34 vs 45 vs 40y old; p < 0.001), had fewer years of surgical experience (2 vs 9 vs 5y; p < 0.001), and had a proportionally higher concentration of residents (p = 0.01).This intensive course is set out as a viable alternative to teach basic skills in advanced laparoscopy in a short period of time, which is ideal for surgeons with difficult access to training centers. It remains necessary to establish the participant profile for which this type of course is most beneficial.Copyright Â© 2015. Published by Elsevier Inc.
Surgical care checklists to optimize patient care following postoperative complications. - American journal of surgery
Postoperative complications are common. Inconsistency in the care of complications is reflected in variable rates of failure to rescue. This study aims to develop and validate checklists for treatment of common postoperative complications.Initial checklists were based on best evidence, with expert clinician review. Casenote review was performed, comparing checklist item completion with outcomes. Logistic regression was performed for risk of further morbidity, considering American Society of Anesthesiology grade, age, sex, and checklist compliance. Checklists were finalized through end user multidisciplinary review.Evidence-based checklists were developed. Retrospective casenote review revealed management of 86% (31/37) of these complications to be noncompliant with checklist-mandated care. This resulted in delays and errors in 65% (24/37) of cases, with median treatment delay of 6 hours (interquartile range 5.4 hours). Regression analysis revealed poor checklist compliance to be to only significant factor (odds ratio 6.75, 95% confidence interval 1.11 to 41.00, P = .038) for developing further morbidity.Management of complications is highly variable, with failure to adhere to best practice principles significantly associated with an increased risk of further morbidity. This study presents an evidence-based framework for the development of checklists to standardize care.Copyright Â© 2015 Elsevier Inc. All rights reserved.
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