Introduction of Physician-Nurse Bedside Rounding and Ward Task List to Improve Quality of Care in Gynaecology: Prospective, Single-Blinded, Pre- and Post-Intervention Study.

OBJECTIVE: This study sought to determine whether physician-nurse bedside rounds and ward task list improve quality of care as measured by patient satisfaction, earlier discharge, and reduced trainee interruptions. METHODS: This prospective, single-blind, pre- and post-intervention study included patients admitted to the gynaecology ward at St. Michael's Hospital in Toronto, Ontario, involving a 6-week baseline, 6-week intervention, and 2-week second baseline phase. During the intervention phase, a chief resident and charge nurse rounded at the bedside simultaneously daily. Nurses recorded non-urgent issues on a ward task list. Patients completed a subset of the National Research Corporation Picker satisfaction questionnaire, discharge times were noted, and residents recorded pages (Canadian Task Force Classification II-2). RESULTS: There were 89, 104, and 30 admissions during baseline care, intervention, and second baseline phases, respectively. Mean discharge time in the intervention phase was significantly earlier than baseline (11:18 am ± 1 hour 59 minutes vs. 12:37 pm ± 2 hours 37 minutes, P < 0.001), with early discharges doubling (69% vs. 36%, P < 0.001). Discharge times returned to baseline after the intervention (12:36 pm ± 2 hours 39 minutes). Intervention phase patients appreciated bedside care plans (86 of 94 patients, 92%), with improved National Research Corporation Picker responses, which diminished post-intervention. Paging interruptions were lower during the intervention phase compared with the baseline phase (1.0 ± 1.1 vs. 3.4 ± 2.1, P < 0.001), with non-urgent pages decreasing most (0.5 ± 0.8 vs. 3.0 ± 2.0, P < 0.001). CONCLUSION: Combining physician-nurse bedside rounds and ward task list reduces trainee interruptions, positively affects patient satisfaction, and promotes early discharge. Following these initiatives, discharge time, patient satisfaction, and resident paging interruptions returned to baseline.

Validating a standardized laparoscopy curriculum for gynecology residents: a randomized controlled trial.

BACKGROUND: Residency programs struggle with integrating simulation training into curricula, despite evidence that simulation leads to improved operating room performance and patient outcomes. Currently, there is no standardized laparoscopic training program available for gynecology residents. OBJECTIVE: The purpose of this study was to develop and validate a comprehensive ex vivo training curriculum for gynecologic laparoscopy. STUDY DESIGN: In a prospective, single-blinded randomized controlled trial (Canadian Task Force Classification I) postgraduate year 1 and 2 gynecology residents were allocated randomly to receive either conventional residency training or an evidence-based laparoscopy curriculum. The 7-week curriculum consisted of cognitive didactic and interactive sessions, low-fidelity box trainer and high-fidelity virtual reality simulator technical skills, and high-fidelity team simulation. The primary outcome measure was the technical procedure score at laparoscopic salpingectomy with the use of the objective structured assessment of laparoscopic salpingectomy tool. Secondary outcome measures related to performance in multiple-choice questions and technical performance at box trainer and virtual reality simulator tasks. A sample size of 10 residents per group was planned (n = 20). Results are reported as medians (interquartile ranges), and data were compared between groups with the Mann-Whitney U, chi-square, and Fisher's exact tests (P ≤ .05). RESULTS: In July 2013, 27 residents were assigned randomly (14 curriculum, 13 conventional). Both groups were similar at baseline. Twenty-one residents (10 curriculum, 11 conventional) completed the surgical procedure-based assessment in the operating room (September to December 2013). Our primary outcome indicated that curriculum-trained residents displayed superior performance at laparoscopic salpingectomy (P = .043). Secondary outcomes demonstrated that curriculum-trained residents had higher performance scores on the cognitive multiple-choice questions (P < .001), the nontechnical skills multiple-choice questions (P = .016), box trainer task time (P < .001), and all virtual reality simulator parameters. CONCLUSION: Participation in a comprehensive simulation-based training curriculum for gynecologic laparoscopy leads to a superior improvement in knowledge and technical performance in the operating room compared with conventional residency training.

Avoiding complications by a hands-on mentor programme.

The complexity of gynaecologic surgery has increased in recent years, while the duration of residency training has remained fixed with reduced work hours compared with our predecessors. Residents may not be graduating with the advanced surgical skill set required for complex cases, which are now considered standard of care. The ever-changing advancements in the field of gynaecologic surgery warrant the development of training programmes for practicing surgeons to incorporate recent advances and best practices. This can be accomplished through mentorship in training residents as well as the continuing professional development of safe gynaecologic surgeons. This review outlines the process of mentorship to enhance surgical skills, and objective feedback tools for surgeons seeking to improve performance. Mentorship programmes can help surgeons incorporate new technologies in a structured environment, which seeks to decrease the risk of complications for our patients.

Designing a Standardized Laparoscopy Curriculum for Gynecology Residents: A Delphi Approach.

BACKGROUND: Evidence suggests that simulation leads to improved operative skill, shorter operating room time, and better patient outcomes. Currently, no standardized laparoscopy curriculum exists for gynecology residents. OBJECTIVE: To design a structured laparoscopy curriculum for gynecology residents using Delphi consensus methodology. METHODS: This study began with Delphi methodology to determine expert consensus on the components of a gynecology laparoscopic skills curriculum. We generated a list of cognitive content, technical skills, and nontechnical skills for training in laparoscopic surgery, and asked 39 experts in gynecologic education to rate the items on a Likert scale (1-5) for inclusion in the curriculum. Consensus was predefined as Cronbach α of ≥0.80. We then conducted another Delphi survey with 9 experienced users of laparoscopic virtual reality simulators to delineate relevant curricular tasks. Finally, a cross-sectional design defined benchmark scores for all identified tasks, with 10 experienced gynecologic surgeons performing the identified tasks at basic, intermediate, and advanced levels. RESULTS: Consensus (Cronbach α=0.85) was achieved in the first round of the curriculum Delphi, and after 2 rounds (Cronbach α=0.80) in the virtual reality curriculum Delphi. Consensus was reached for cognitive, technical, and nontechnical skills as well as for 6 virtual reality tasks. Median time and economy of movement scores defined benchmarks for all tasks. CONCLUSIONS: This study used Delphi consensus to develop a comprehensive curriculum for teaching gynecologic laparoscopy. The curriculum conforms to current educational standards of proficiency-based training, and is suggested as a standard in residency programs.

The Generic Error Rating Tool: A Novel Approach to Assessment of Performance and Surgical Education in Gynecologic Laparoscopy.

OBJECTIVE: Global rating scales are commonly used to rate surgeons' skill level. However, these tools lack granularity required for specific skill feedback. Recently, an alternative framework has been developed that is designed to measure technical errors during laparoscopy. The purpose of the present study was to gather validity evidence for the Generic Error Rating Tool (GERT) in gynecologic laparoscopy. DESIGN: Video recordings of total laparoscopic hysterectomies were analyzed by 2 blinded reviewers using the GERT and the Objective Structured Assessment of Technical Skills (OSATS) scale. Several sources of validity were examined according to the unitary framework of validity. Main outcomes were interrater and intrarater reliability regarding total number of errors and events. Further, surgeons were grouped according to OSATS scores (OSATS ≥ 28 = high performers and OSATS < 28 = low performers), and the number of errors and events was compared between groups. Correlation analysis between GERT and OSATS scores was performed. Lastly, error distribution within procedure steps was explored and compared between high- and low-performing surgeons. SETTING: University teaching hospital. PARTICIPANTS: A total of 20 anonymized video recordings of total laparoscopic hysterectomies. RESULTS: Interrater and intrarater reliability was high (intraclass correlation coefficient >0.95) for total number of errors and events. Low performers made significantly more errors than high performers did (median = 49.5 [interquartile range: 34.5-66] vs median = 31 [interquartile range: 16.75-35.25], p = 0.002). There was a significant negative correlation between individual OSATS scores and total number of errors (Spearman ρ = -0.76, p < 0.001, and ρ = -0.88, p < 0.001, for raters 1 and 2, respectively). Error distribution varied between operative steps, and low performers made more errors in some steps, but not in others. CONCLUSION: GERT allows for objective and reproducible assessment of technical errors during gynecologic laparoscopy and could be used for performance analysis and personalized surgical education and training.

Gynecology resident laparoscopy training: present and future.

Simulator education is essential to surgical training and it should be a requirement at all training programs across North America. Yet, in a survey of North American obstetrics and gynecology program directors (response rate 52%), we found that while 73% (n = 98) of programs teach laparoscopic skills, only 59% (n = 81) were satisfied with their curriculum. Most programs lacked standard setting in the form of theoretical examinations (94%, n = 127) or skills assessments (91%, n = 123) prior to residents performing surgery on patients in the operating room. Most programs (97%, n = 131) were interested in standardizing laparoscopy education by implementing a common curriculum. We present 3 core recommendations to ensure that gynecologists across North America are receiving adequate training in gynecologic laparoscopic surgery as residents: (1) uniform simulator education should be implemented at all training programs across North American residency programs; (2) a standardized curriculum should be developed using evidence-based techniques; and (3) standardized assessments should take place prior to operating room performance and specialty certification. Future collaborative research initiatives should focus on establishing the content of a standardized laparoscopy curriculum for gynecology residents utilizing a consensus method approach.

Vaginal hysterectomy: dispelling the myths.

Despite advances in minimally invasive surgery, most hysterectomies are still performed by laparotomy. The ratio of abdominal to vaginal hysterectomies ranges from 1:1 to 6:1 across North America, and in Canada is approximately 3:1. The SOGC clinical practice guideline on hysterectomy states that the vaginal route should be considered for every hysterectomy; if it is assumed that most surgeons would try to follow accepted guidelines, vaginal hysterectomy is presumably being considered and excluded. The evidence is compelling that vaginal hysterectomy is the approach of choice for benign pathology. The cited contraindications to vaginal hysterectomy are often unsubstantiated. In this commentary we examine the four reasons most often cited for avoiding a vaginal hysterectomy: (1) uterine size, (2) nulliparity and uterine descent, (3) need for oophorectomy, and (4) previous abdominopelvic surgery and extrauterine disease. More research is necessary to evaluate and demystify the barriers to performing minimally invasive hysterectomy. We recommend that preceptorship programs be developed for gynaecologic surgeons in an attempt to decrease the ratio of abdominal to vaginal hysterectomies.

RETIRED: Uterine fibroid embolization (UFE).

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