A systematic review of surgical skills transfer after simulation-based training: laparoscopic cholecystectomy and endoscopy.

OBJECTIVE: A systematic review to determine whether skills acquired through simulation-based training transfer to the operating room for the procedures of laparoscopic cholecystectomy and endoscopy. BACKGROUND: Simulation-based training assumes that skills are directly transferable to the operation room, but only a few studies have investigated the effect of simulation-based training on surgical performance. METHODS: A systematic search strategy that was used in 2006 was updated to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. RESULTS: Seventeen randomized controlled trials and 3 nonrandomized comparative studies were included in this review. In most cases, simulation-based training was in addition to patient-based training programs. Only 2 studies directly compared simulation-based training in isolation with patient-based training. For laparoscopic cholecystectomy (n = 10 studies) and endoscopy (n = 10 studies), participants who reached simulation-based skills proficiency before undergoing patient-based assessment performed with higher global assessment scores and fewer errors in the operating room than their counterparts who did not receive simulation training. Not all parameters measured were improved. Two of the endoscopic studies compared simulation-based training in isolation with patient-based training with different results: for sigmoidoscopy, patient-based training was more effective, whereas for colonoscopy, simulation-based training was equally effective. CONCLUSIONS: Skills acquired by simulation-based training seem to be transferable to the operative setting for laparoscopic cholecystectomy and endoscopy. Future research will strengthen these conclusions by evaluating predetermined competency levels on the same simulators and using objective validated global rating scales to measure operative performance.

Telehealth on advanced networks.

We address advanced Internet for complex telehealth applications by reviewing four hospital-based broadband telehealth projects and identifying common threads. These projects were conducted in Australia under a 6-year research project on broadband Internet applications. Each project addressed specific clinical needs and its development was guided by the clinicians involved. Each project was trialed in the field and evaluated against the initial requirements. The four projects covered remote management of a resuscitation team in a district hospital, remote guidance and interpretation of echocardiography, virtual-reality-based instructor-student surgical training, and postoperative outpatient consultations following pediatric surgery. Each was characterized by a high level of interpersonal communication, a high level of clinical expertise, and multiple participants. Each made use of multiple high-quality video and audio links and shared real-time access to clinical data. Four common threads were observed. Each application provided a high level of usability and task focus because the design and use of broadband capability was aimed directly to meet the clinicians' needs. Each used the media quality available over broadband to convey words, gestures, body movements, and facial expressions to support communication and a sense of presence among the participants. Each required a complex information space shared among the participants, including real-time access to stored patient data and real-time interactive access to the patients themselves. Finally, each application supported the social and organizational aspects of their healthcare focus, creating and maintaining relationships between the various participants, and this was done by placing the telehealth application into a wider functioning clinical context. These findings provide evidence for a significantly enhanced role for appropriate telemedicine systems running on advanced networks, in a wider range of clinical applications, more deeply integrated into healthcare systems.

A systematic review of skills transfer after surgical simulation training.

OBJECTIVE: To determine whether skills acquired by simulation-based training transfer to the operative setting. SUMMARY BACKGROUND DATA: The fundamental assumption of simulation-based training is that skills acquired in simulated settings are directly transferable to the operating room, yet little evidence has focused on correlating simulated performance with actual surgical performance. METHODS: A systematic search strategy was used to retrieve relevant studies. Inclusion of articles was determined using a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Only studies that reported on the use of simulation-based training for surgical skills training, and the transferability of these skills to the operative setting, were included. RESULTS: Ten randomized controlled trials and 1 nonrandomized comparative study were included in this review. In most cases, simulation-based training was in addition to normal training programs. Only 1 study compared simulation-based training with patient-based training. For laparoscopic cholecystectomy and colonoscopy/sigmoidoscopy, participants who received simulation-based training before undergoing patient-based assessment performed better than their counterparts who did not receive previous simulation training, but improvement was not demonstrated for all measured parameters. CONCLUSIONS: Skills acquired by simulation-based training seem to be transferable to the operative setting. The studies included in this review were of variable quality and did not use comparable simulation-based training methodologies, which limited the strength of the conclusions. More studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs.

High stakes assessment using simulation -- an Australian experience.

The use of simulation for high stakes assessment has been embedded in the New South Wales Medical Practice Act and has been used for high stakes assessment on a number of occasions. Simulation has rarely been used in this manner elsewhere in the world. We outline the use of simulation in particular focussing on its relationship to a performance assessment programme featuring performance focus, peer assessment of standards, an educative, remedial and protective framework, strong legislative support and system awareness.

The ViCCU Project -- achieving virtual presence using Ultrabroadband internet in a Critical Clinical application -- initial results.

The ViCCU (Virtual Critical Care Unit) Project sought to address the problems of shortages of Critical Care staff by developing a system that could use the capabilities of Ultrabroadband networks so as to have a Critical Care Specialist virtually present at a distant location. This is not possible in a clinically useful way with current systems. A new system (ViCCU) was developed and deployed. Critically ill or injured patients are now routinely assessed and managed remotely using this system. It has led to a more appropriate level of transfers of patients and the delivery of a quality of clinical service not previously available. This paper describes the history of the project, its novelty, the clinically significant technical aspects of the system and its deployment. The initial results to the end of September 2004 are described.

Novel single-nucleotide polymorphisms in the calsequestrin-1 gene are associated with Graves' ophthalmopathy and Hashimoto's thyroiditis.

BACKGROUND: The eye disorder associated with Graves' disease, called Graves' ophthalmopathy (GO), greatly reduces the quality of life in affected patients. Expression of the calsequestrin (CASQ1) protein in thyroid tissue may be the trigger for the development of eye muscle damage in patients with GO. We determined the prevalence of rs74123279, rs3747673, and rs2275703 single-nucleotide polymorphism (SNPs) in patients with autoimmune thyroid disorders, GO, Graves' hyperthyroidism (GH), or Hashimoto's thyroiditis (HT) and control subjects with no personal or family history of autoimmune thyroid disorders. Furthermore, we measured the concentration of the CASQ1 protein in normal and Graves' thyroid tissue, correlating levels with parameters of the eye signs, CASQ1 antibody levels, and the CASQ1 gene polymorphism rs74123279 and rs2275703. METHODS: High-quality genomic DNA was isolated from fresh blood samples, assayed for identification of rs74123279, rs3747673, and rs2275703 SNPs in CASQ1 gene by MassARRAY SNP analysis using iPLEX technology of SEQUENOM. RESULTS: DNA samples from 300 patients and 106 control subjects (100 males, 306 females) with GO (n=74), GH (n=130), HT (n=96) and control subjects (n=106) were genotyped for the SNPs rs74123279, rs3747673 (n=405), and rs2275703 (n=407). The SNP rs74123279, rs3747673, and rs2275703 were identified as 1) common homozygous or wild type, 2) heterozygote, and 3) rare homozygous. Minor allele frequency for rs74123279, rs3747763, and rs2275703 were 21%, 40%, and 44%, respectively. Multiple comparisons of genotype frequency for rs74123279, rs3747763, and rs2275703 in the GO, GH, HT, and control groups showed P=0.06, 0.641, and 0.189, respectively. These results were substantiated by multiple comparison of alleles frequency for rs74123279, rs3838216, rs3747763, and rs2275703 in the GO, GH, HT, and control groups showed, P=0.36, 0.008, 0.66, and 0.05, respectively. Pairwise analysis of alleles frequency distribution in patients with GO showed significant probability for rs2275703, P=0.008. CONCLUSION: Based on their evolutionary conservation and their significant prevalence, we suggest that CASQ1 gene SNPs rs74123279, rs3838216, and rs2275703 may be considered as genetic markers for GO.

Virtual reality simulators: current status in acquisition and assessment of surgical skills.

Medical technology is currently evolving so rapidly that its impact cannot be analysed. Robotics and telesurgery loom on the horizon, and the technology used to drive these advances has serendipitous side-effects for the education and training arena. The graphical and haptic interfaces used to provide remote feedback to the operator--by passing control to a computer--may be used to generate simulations of the operative environment that are useful for training candidates in surgical procedures. One additional advantage is that the metrics calculated inherently in the controlling software in order to run the simulation may be used to provide performance feedback to individual trainees and mentors. New interfaces will be required to undergo evaluation of the simulation fidelity before being deemed acceptable. The potential benefits fall into one of two general categories: those benefits related to skill acquisition, and those related to skill assessment. The educational value of the simulation will require assessment, and comparison to currently available methods of training in any given procedure. It is also necessary to determine--by repeated trials--whether a given simulation actually measures the performance parameters it purports to measure. This trains the spotlight on what constitutes good surgical skill, and how it is to be objectively measured. Early results suggest that virtual reality simulators have an important role to play in this aspect of surgical training.

Surgical services: shaping future directions.

BACKGROUND: Advances in surgical techniques and anaesthetic practise have facilitated a significant change in the way surgery is currently delivered. In particular, short stay surgery including ambulatory surgery has become the norm for the majority of surgical conditions. However, the planning of surgical services has not always kept pace with nor capitalised on these clinical advances. Like many major urban centres in Australia, the Greater Sydney region is changing, in terms of population growth and configuration of clinical and operational networks. In conjunction with NSW Department of Health, the ministerially appointed Surgical Services Taskforce was tasked with determining the shape and direction of surgery in Greater Sydney over the next 5 to 10 years. METHODS: Over 400 clinicians either attended hospitals forums or were contacted by the Surgery Futures project team. RESULTS: From the consultations, three models of service delivery were strongly advocated. These were the development of high volume short stay surgery centres, the establishment of specialty centres and the expansion of the streaming of planned and emergency surgery. CONCLUSION: These three major recommendations will require a significant reorganisation of surgical services in NSW. However, they are also relevant to surgical services planning elsewhere in Australia. It is imperative that these recommendations are incorporated into long term surgical planning in order to improve the efficiency and sustainability of surgical service delivery.

Making sense of emergency surgery in New South Wales: a position statement.

BACKGROUND: Emergency surgery is a major component of the provision of surgical services and makes up a substantial volume of the workload of surgeons in many hospitals. It is often more complex and surgically challenging than elective surgery. However, little attention has been concentrated on the management or resource requirements of emergency surgery. METHOD: This article identifies principles for models of emergency surgery care and describes how they can be incorporated into a redesign of emergency surgery. They have been developed and are endorsed by experienced surgical staff routinely coping with the challenges of emergency surgery. RESULTS: The benefits of redesigning emergency surgery will be realized by an active partnership between managers, surgeons and surgical teams. The anticipated clinical benefits include improved patient outcomes, enhanced patient and surgical team satisfaction, and increased trainee supervision in emergency surgery. Significant management benefits will ensue from high rates of emergency operating theatre utilization, reduced patient cancellations and reduction in after-hours costs. This unplanned but predictable workload will be managed in a planned and predictable fashion. CONCLUSION: Reform of emergency surgery services is a necessity and not a choice. The development of the emergency surgery guidelines for New South Wales is a step in the right direction. The principles identified in the guidelines should be adapted and implemented across Australia if sustainable, safe and efficient emergency surgery services are to be provided. Patients will expect nothing less.

Acute Surgical Unit: a new model of care.

The traditional on-call system for the management of acute general surgical admissions is inefficient and outdated. A new model, Acute Surgical Unit (ASU), was developed at Nepean Hospital in 2006. The ASU is a consultant-driven, independent unit that manages all acute general surgical admissions. The team has the same make up 7 days a week and functions the same every day, including weekends and public holidays. The consultant does a 24-h period of on-call, from 7 pm to 7 pm. They are on remote call from 7 pm to 7 am and are in the hospital from 7 am to 7 pm with their sole responsibility being to the ASU. The ASU has a day team with two registrars, two residents and a nurse practitioner. All patients are admitted and stay in the ASU until discharge or transfer to other units. Handover of the patients at the end of each day is facilitated by a comprehensive ASU database. The implementation of the ASU at Nepean Hospital has improved the timing of assessment by the surgical unit. There has been significant improvement in the timing of operative management, with an increased number and proportion of cases being done during daylight hours, with an associated reduction in the proportion of cases performed afterhours. There is greater trainee supervision with regard to patient assessment, management and operative procedures. There has been an improvement in the consultants' work conditions. The ASU provides an excellent training opportunity for surgical trainees, residents and interns in the assessment and management of acute surgical conditions.

Applying clinical process redesign methods to planned arrivals in New South Wales hospitals.

*Competing demands of planned and unplanned arrivals present major challenges for hospitals. *Applying clinical process redesign methods to the planned patient journey allows management to recognise the blocks and inefficiencies in the journey and facilitates the development of solutions for improvement. *Redesign of the planned patient journey in New South Wales has promoted the expansion of the extended day-only model of care, reformed the waiting times policy, standardised patient preadmission assessment and preparation, and targeted operating theatre use. *Improved performance management at Area Health Service and local facility levels has accompanied the redesign of planned arrival processes. *The results in redesign of surgery undertaken by the Area Health Services in 96 NSW hospitals have been impressive, with results within 2 years of commencing the clinical services redesign program showing: a 97% reduction in the numbers of patients in Category 1 (admission desirable within 30 days) whose surgery was overdue, from 5308 in January 2005 to 135 in June 2007; and a 99% reduction in the number of patients who have waited > 365 days for surgery, from 10 551 in January 2005 to 84 in June 2007. *Improved surgical service efficiency, safety and quality justify the continuation of the redesign program.

Impact of an ultrabroadband emergency department telemedicine system on the care of acutely ill patients and clinicians' work.

OBJECTIVES: To evaluate whether introduction of an emergency department (ED) telemedicine system changed patient management and outcome indicators and to investigate clinicians' perceptions of the impact of the system on care provided and on their work. DESIGN: Before-and-after study of use of the Virtual Critical Care Unit (ViCCU), which uses an ultrabroadband connection allowing real-time audiovisual communication between clinicians at distant sites. Semi-structured interviews were conducted with medical and nursing staff at the end of the study. PARTICIPANTS AND SETTING: The ViCCU intervention commenced on 1 January 2004. Our study was conducted in the EDs of an 85-bed district hospital and a 420-bed metropolitan tertiary hospital. It involved all acutely ill patients requiring urgent care (defined by triage category and grouped into critical care, major trauma and moderate trauma) who were treated during the 12 months before (n=169) and 18 months after (n=181) the intervention at the district hospital. Thirty-one of 33 clinicians (doctors and nurses) participating at the two hospitals took part in interviews at the end of the study. MAIN OUTCOME MEASURES: Changes in patterns of management (disposition [admission, discharge or transfer], treatment times, number of procedures) and outcomes (rapid acute physiology scores, hours on ventilation or in intensive care, length of stay). RESULTS: Patient disposition remained unaltered for major trauma patients. For critical care patients, admissions fell significantly (54% to 30%), transfers increased (21% to 39%), and more procedures were performed. For moderate trauma patients, discharges increased significantly (45% to 63%), transfers decreased (48% to 25%) and treatment times were longer. No significant changes were found in outcome indicators. Clinicians reported that the ViCCU allowed greater support to remote clinicians. Specialists reported increased workloads and feelings of greater responsibility for patients at the district hospital. Nurses at the district site reported reduced stress, but district doctors reported some loss of autonomy. CONCLUSIONS: The ViCCU appears most effective for moderate trauma patients, with associated reductions in admissions and transfers. Large-scale trials of telemedicine systems that include measurements of both patient care and impact on clinicians' work are required.

Development of a broadband telehealth system for critical care: process and lessons learned.

A broadband telehealth system has been developed for supporting critical care services between a major referral hospital and a rural hospital by transmitting very high-quality, realtime multimedia information, including images, audio and real-time video, over an Internet Protocol (IP)-based network. The technical design team took an iterative and user-centred approach toward the system design. Usability tests with scenario analysis were incorporated into the development process to produce a system that operates seamlessly in the critical care environment. Careful analysis of the reliability of the system was incorporated into the clinical protocols for integration into existing work practices. The use of high-quality multimedia data, consideration of human factors early in the design process, and incorporation of proper development approaches were critical for the success of the system design.

Surgical simulation: a systematic review.

OBJECTIVE: To evaluate the effectiveness of surgical simulation compared with other methods of surgical training. SUMMARY BACKGROUND DATA: Surgical simulation (with or without computers) is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they operate on humans. METHODS: Studies were identified through searches of MEDLINE, EMBASE, the Cochrane Library, and other databases until April 2005. Included studies must have been randomized controlled trials (RCTs) assessing any training technique using at least some elements of surgical simulation, which reported measures of surgical task performance. RESULTS: Thirty RCTs with 760 participants were able to be included, although the quality of the RCTs was often poor. Computer simulation generally showed better results than no training at all (and than physical trainer/model training in one RCT), but was not convincingly superior to standard training (such as surgical drills) or video simulation (particularly when assessed by operative performance). Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training. CONCLUSIONS: While there may be compelling reasons to reduce reliance on patients, cadavers, and animals for surgical training, none of the methods of simulated training has yet been shown to be better than other forms of surgical training.

The easiest cut: managing elective surgery in the public sector.

The problem of surgical waiting lists requires multifactorial solutions.