Intra-operative ultrasound assessment of the biliary tree during robotic cholecystectomy.

Image-guided assessment of bile ducts and associated anatomy during laparoscopic cholecystectomy can be achieved with intra-operative cholangiography (IOC) or laparoscopic ultrasound (LUS). Rates of robotically assisted cholecystectomy (RC) are increasing and herein we describe the technique of intra-corporeal biliary ultrasound during RC using the Da Vinci system. For intraoperative evaluation of the biliary tree during RC, in cases of suspected choledocholithiasis, the L51K Ultrasound Probe (Hitachi, Tokyo, Japan) is used. The extrahepatic biliary tree is scanned along its length, capitalising on the benefits of the full range of motion offered by the articulated robotic instruments and integrated ultrasonic image display using TileProTM software. Additionally, this technique avoids the additional time and efforts required to undock and re-dock the robot that would otherwise be required for selective IOC or LUS. The average time taken to perform a comprehensive evaluation of the biliary tree, from the hepatic ducts to the ampulla of Vater, is 164.1 s. This assessment is supplemented by Doppler ultrasound, which is used to fully delineate anatomy of the porta hepatis, and accurate measurements of the biliary tree and any ductal stones can be taken, allowing for contemporaneous decision making and management of ductal pathologies. Biliary tract ultrasound has been shown to be equal to IOC in its ability to diagnose choledocholithiasis, but with the additional benefits of being quicker and having higher completion rates. We have described our practice of using biliary ultrasound during robotically assisted cholecystectomy, which is ergonomically superior to LUS, accurate and reproducible.

Key Components of the Safe Surgical Ward: International Delphi Consensus Study to Identify Factors for Quality Assessment and Service Improvement.

OBJECTIVE: The aim of this study was to prioritize key factors contributing to safety on the surgical ward BACKGROUND:: There is a variation in the quality and safety of postoperative care between institutions. These variations may be attributed to a combination of process-related issues and structural factors. The aim of this study is to reach a consensus, by means of Delphi methodology, on the most influential of these components that may determine safety in this environment. METHODS: The Delphi questionnaire was delivered via an online questionnaire platform. The panel were blinded. An international panel of safety experts, both clinical and nonclinical, and safety advocates participated. Individuals were selected according to their expertise and extent of involvement in patient safety research, regulation, or patient advocacy. RESULTS: Experts in patient safety from the UK, Europe, North America, and Australia participated. The panel identified the response to a deteriorating patient and the care of outlier patients as error-prone processes. Prioritized structural factors included organizational and environmental considerations such as use of temporary staff, out-of-hours reduction in services, ward cleanliness, and features of layout. The latter includes dedicated areas for medication preparation and adequate space around the patient for care delivery. Potential quality markers for safe care that achieved the highest consensus include leadership, visibility between patients and nurses, and nursing team skill mix and staffing levels. CONCLUSION: International consensus was achieved for a number of factors across process-related and structural themes that may influence safety in the postoperative environment. These should be championed and prioritized for future improvements in patient safety at the ward-level.

Measuring Decision-Making During Thyroidectomy: Validity Evidence for a Web-Based Assessment Tool.

BACKGROUND: Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them. METHODS: An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from four institutions completed a 33-item assessment, developed based on a cognitive task analysis and expert Delphi consensus. Sixteen items required subjects to make annotations on still frames of thyroidectomy videos, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test," VCT). Seven items were short answer (SA), requiring users to type their answers, and scores were automatically calculated based on their similarity to a pre-populated repertoire of correct responses. Test-retest reliability, internal consistency, and correlation of scores with self-reported experience and training level (novice, intermediate, expert) were calculated. RESULTS: Twenty-eight subjects (10 endocrine surgeons and otolaryngologists, 18 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.96; n = 10) and internal consistency (Cronbach's α = 0.93). The assessment demonstrated significant differences between novices, intermediates, and experts in total score (p < 0.01), VCT score (p < 0.01) and SA score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.95, p < 0.01), between total case number and VCT score (ρ = 0.93, p < 0.01), and between total case number and SA score (ρ = 0.83, p < 0.01). CONCLUSION: This study describes the development of novel metrics and provides validity evidence for an interactive Web-based platform to objectively assess decision-making during thyroidectomy.

Demand for specialised training for the obese trauma patient: National ATLS expert group survey results.

BACKGROUND: The growing incidence of obesity in Western populations continues to place new stressors on health systems. Obese trauma patients present particular challenges across the entirety of the patient care pathway, and are at risk of higher lengths of stay, morbidity, and mortality. This study sought to assess a national group of trauma experts' opinions and knowledge regarding the management of obese trauma. METHODS: A questionnaire was circulated to a trauma training providers and national steering committee members at a UK national Advance Trauma Life Support meeting. Demographic, knowledge, and opinion data was collected and collated for analysis. RESULTS: 109 questionnaires were returned (73% response rate). Broad agreement was reached that obese trauma patients were more challenging to manage (96.2% agreement) and suffered worse outcomes (89.9%). Only 22.2% felt their hospitals possessed appropriate resources to facilitate management. Up to a third of respondents had personally witnesses errors in care due to patient obesity. 90% believed specialist training for obese trauma could improve care. DISCUSSION: There is broad consensus amongst UK trauma providers that obese trauma patients are at risk of poorer outcomes and errors in care. Knowledge and preparedness of centres to manage these patients is variable. There was broad consensus that specialist training for the management of obese trauma patients may improve outcomes.

Measuring intra-operative decision-making during laparoscopic cholecystectomy: validity evidence for a novel interactive Web-based assessment tool.

BACKGROUND: Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries and other complications. Despite correlations between outcomes, expertise and advanced cognitive skills, current methods to evaluate these skills remain subjective, rater- and situation-dependent and non-systematic. The purpose of this study was to develop objective metrics using a Web-based platform and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy. METHODS: An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from six institutions completed a 12-item assessment, developed based on a cognitive task analysis. Five items required subjects to draw their answer on the surgical field, and accuracy scores were calculated based on an algorithm derived from experts' responses ("visual concordance test", VCT). Test-retest reliability, internal consistency, and correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated. Questionnaires were administered to evaluate the platform's usability, feasibility and educational value. RESULTS: Thirty-nine subjects (17 surgeons, 22 trainees) participated. There was high test-retest reliability (intraclass correlation coefficient = 0.95; n = 10) and internal consistency (Cronbach's α = 0.87). The assessment demonstrated significant differences between novices, intermediates and experts in total score (p < 0.01) and VCT score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.83, p < 0.01) and between total case number and VCT (ρ = 0.82, p < 0.01), and moderate to high correlations between total score and GOALS (ρ = 0.66, p = 0.05), VCT and GOALS (ρ = 0.83, p < 0.01), total score and OPRS (ρ = 0.67, p = 0.04), and VCT and OPRS (ρ = 0.78, p = 0.01). Most subjects agreed or strongly agreed that the platform and assessment was easy to use [n = 29 (78 %)], facilitates learning intra-operative decision-making [n = 28 (81 %)], and should be integrated into surgical training [n = 28 (76 %)]. CONCLUSION: This study provides preliminary validity evidence for a novel interactive platform to objectively assess decision-making during laparoscopic cholecystectomy.

Development, Organisation and Implementation of a Surgical Skills 'Boot Camp': SIMweek.

BACKGROUND: There is evidence of increased mortality and reduced efficiency in hospitals due to the annual changeover of junior doctors. This paper describes a framework to develop an intensive simulated week that will recreate experiences and situations that junixor surgical interns will likely face in their first weeks after graduation. METHODS: To provide evidence-based recommendations, a systematic review of published literature using the keywords 'surg*', 'boot', 'camp' was performed. Reports of the development, implementation or evaluation of a simulated skills course or 'boot camp' to prepare incoming surgical interns were analysed. RESULTS: Eighteen relevant articles were identified. Subjects on internship preparation courses have identified 'hands-on' training sessions to be very useful. In particular, mock pages have been identified as being valuable and didactic lectures have been identified as the weakest parts of the course. We first consider the end-users of the course and their associated learning needs. We subsequently discuss resources required and propose a strategy for the organisation of a course and selection of teaching faculty. Finally, we consider the costs involved in running a course. CONCLUSIONS: This paper proposes a framework for the development, organisation and implementation of an intensive simulation course to prepare graduating medical students for their role as junior surgical intern. Facilitating the step change in responsibility from student to surgical intern may improve patient safety in addition to reducing the associated anxiety for the clinician.

Consumer demand for surgical innovation: a systematic review of public perception of NOTES.

BACKGROUND: The full scope of benefits offered by NOTES over traditional laparoscopy, if any, is not yet fully clear. Perceived patient demand for truly "scarless surgery" is often referenced one of the driving factors in the continued development of this relatively new technique. The true scale of patient preference and demand for NOTES as a surgical technique is unknown. This review aims to summarise currently available literature on the topic of patient perceptions of NOTES to guide future development of the technique. METHODS: A comprehensive search of PubMed and Web of Science electronic databases was performed on 1st Jan 2014. To be considered for inclusion, articles were required to assess and report the perception of NOTES in a sample of laypersons (patients or general public). The primary endpoint assessed was acceptance or preference rates expressed by patients for NOTES procedures. Reasons given for preference or rejection of NOTES were recorded, as well as preferred access routes and any predicting factors of NOTES acceptance. RESULTS: Initial search returned 1,334 results, resulting in 15 articles included in final data synthesis. These polled a total of 4,420 subjects. Acceptance of NOTES ranged between 41 and 84 %. Compared to a laparoscopic approach, preference rates for NOTES ranged from 0 to 78 %. Reasons for preferring NOTES were largely centred on potentially reduced recovery time, complications (particularly with reference to hernias) and postoperative pain. Improved cosmesis also played a role, but was secondary to the above issues. Overall, study quality was poor. CONCLUSIONS: This review suggests significant public interest in NOTES and scarless surgery in general. Further research and consideration of differences in public perceptions across regions, countries and cultures are required.

Eye tracking for skills assessment and training: a systematic review.

BACKGROUND: The development of quantitative objective tools is critical to the assessment of surgeon skill. Eye tracking is a novel tool, which has been proposed may provide suitable metrics for this task. The aim of this study was to review current evidence for the use of eye tracking in training and assessment. METHODS: A systematic literature review was conducted in line with PRISMA guidelines. A search of EMBASE, OVID MEDLINE, Maternity and Infant Care, PsycINFO, and Transport databases was conducted, till March 2013. Studies describing the use of eye tracking in the execution, training or assessment of a task, or for skill acquisition were included in the review. RESULTS: Initial search results returned 12,051 results. Twenty-four studies were included in the final qualitative synthesis. Sixteen studies were based on eye tracking in assessment and eight studies were on eye tacking in training. These demonstrated feasibility and validity in the use of eye tracking metrics and gaze tracking to differentiate between subjects of varying skill levels. Several training methods using gaze training and pattern recognition were also described. CONCLUSIONS: Current literature demonstrates the ability of eye tracking to provide reliable quantitative data as an objective assessment tool, with potential applications to surgical training to improve performance. Eye tracking remains a promising area of research with the possibility of future implementation into surgical skill assessment.

Nontechnical skills performance and care processes in the management of the acute trauma patient.

BACKGROUND: Acute trauma management is a complex process, with the effective cooperation among multiple clinicians critical to success. Despite this, the effect of nontechnical skills on performance on outcomes has not been investigated previously in trauma. METHODS: Trauma calls in an urban, level 1 trauma center were observed directly. Nontechnical performance was measured using T-NOTECHS. Times to disposition and completion of assessment care processes were recorded, as well as any delays or errors. Statistical analysis assessed the effect of T-NOTECHS on performance and outcomes, accounting for Injury Severity Scores (ISS) and time of day as potential confounding factors. Meta-analysis was performed for incidence of delays. RESULTS: Fifty trauma calls were observed, with an ISS of 13 (interquartile range [IQR], 5-25); duration of stay 1 (IQR, 1-8) days; T-NOTECHS, 20.5 (IQR, 18-23); time to disposition, 24 minutes (IQR, 18-42). Trauma calls with low T-NOTECHS scores had a greater time to disposition: 35 minutes (IQR, 23-53) versus 20 (IQR, 16-25; P = .046). ISS showed a significant correlation to duration of stay (r = 0.736; P < .001), but not to T-NOTECHS (r = 0.201; P = .219) or time to disposition (r = 0.113; P = .494). There was no difference between "in-hours" and "out-of-hours" trauma calls for T-NOTECHS scores (21 [IQR, 18-22] vs 20 [IQR, 20-23]; P = .361), or time to disposition (34 minutes [IQR, 24-52] vs 17 [IQR, 15-27]; P = .419). Regression analysis revealed T-NOTECHS as the only factor associated with delays (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.06-0.95). CONCLUSION: Better teamwork and nontechnical performance are associated with significant decreases in disposition time, an important marker of quality in acute trauma care. Addressing team and nontechnical skills has the potential to improve patient assessment, treatment, and outcomes.

Enhancing surgical performance outcomes through process-driven care: a systematic review.

BACKGROUND: Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care. METHODS: A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded. RESULTS: Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear. CONCLUSION: Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.

Validation of the simulated ward environment for assessment of ward-based surgical care.

OBJECTIVE: To assess the feasibility of developing a simulated ward environment in which to assess the ward-based care of surgical patients by clinicians of varying levels of experience (construct validation). BACKGROUND: Increasing evidence points to the importance of the postoperative or ward-based phase of surgical care in determining patient outcomes. Ward-based care is determined by the clinician ward round, with the simulated ward environment potentially providing a safe environment for training and assessment. METHODS: A high-fidelity surgical ward environment was developed. Junior and senior trainees conducted ward rounds of 3 standardized surgical patients and were assessed using a checklist of assessment and management care processes, modified NOTECHS score, and fidelity questionnaire. RESULTS: Nine senior and 9 junior trainees were observed. There was no significant difference in time taken to conduct the round (37.6 ± 2.7 vs 32.6 ± 1.9 minutes, P = 0.16). Senior trainees performed significantly more assessment processes (73% ± 2.8% vs 63% ± 2.5%, P = 0.016) and completed more management tasks (73% ± 4.5% vs 59.4% ± 5%, P = 0.058). Fifteen adverse events were committed by junior trainees versus 8 by seniors (P < 0.001). Seniors scored higher on nontechnical ability (NOTECHS score 21.8 ± 0.61 vs 18.1 ± 1.12, P = 0.017). All of subjects felt the ward, patients, and scenarios were realistic. CONCLUSIONS: A high-fidelity, immersive, construct-valid ward simulator has been developed in which to observe and assess ward-based processes of surgical care.

A growing problem: implications of obesity on the provision of trauma care.

The incidences of both trauma and obesity are rapidly on the rise. Whilst dedicated trauma centres exist, these may not be equipped to manage obese and super-obese patients' unique medical and surgical demands. This review assesses the impact of trauma on the obese patient and the specialist considerations required in their management throughout pre-hospital, acute and inpatient phases of trauma care. Specific recommendations for the necessary infrastructure and equipment are made to ensure optimal care of the obese trauma patient. We also review evidence-based best practice in the assessment, diagnosis and treatment of this patient group. Only by addressing the unique needs of obese trauma patients with specialist education, equipment and infrastructure can optimal patient outcomes be assured.

Global lessons on transforming strategy into action to save mothers' lives.

Although many countries remain far from achieving the reduction in maternal mortality stipulated by Millennium Development Goal (MDG) 5, 13 are on track to achieve this goal-despite experiencing similar fiscal, workforce, and other constraints as lower-performing peers. The present article assesses existing literature and successful local examples to allow health leaders to learn from these global success stories. A key lesson is that clinical interventions are not enough. Basic care provision must be supplemented with interventions that stimulate demand for services and ensure that they are both affordable and physically accessible. At US $1-6 per woman, comprehensive programs need not exert unsustainable pressure on health budgets. But perhaps more important is how this "ecosystem" of interventions is implemented. We identify 5 principles that characterize successful implementation: embedding maternal health as a top priority; focusing on targeted effective initiatives; fostering strong local ownership; maximizing efficiency and use of available resources; and creating a tough system of national accountability. Together, they offer policymakers and health leaders principles with which to accelerate progress toward MDG 5. With so many women's lives at stake, there could hardly be a greater incentive to do so.

Simulation for ward processes of surgical care.

The role of simulation in surgical education, initially confined to technical skills and procedural tasks, increasingly includes training nontechnical skills including communication, crisis management, and teamwork. Research suggests that many preventable adverse events can be attributed to nontechnical error occurring within a ward context. Ward rounds represent the primary point of interaction between patient and physician but take place without formalized training or assessment. The simulated ward should provide an environment in which processes of perioperative care can be performed safely and realistically, allowing multidisciplinary assessment and training of full ward rounds. We review existing literature and describe our experience in setting up our ward simulator. We examine the facilities, equipment, cost, and personnel required for establishing a surgical ward simulator and consider the scenario development, assessment, and feedback tools necessary to integrate it into a surgical curriculum.