Assessment of laparoscopic surgery practice, knowledge, and training goals in Liberia: A mixed-methods study among Liberian surgeons.

BACKGROUND: Laparoscopy training remains inaccessible in many low- and middle-income countries, including Liberia. We assessed the availability of laparoscopy and feasibility of implementing a laparoscopic program among Liberian surgeons and trainees. METHODS: This mixed-methods study utilized a 32-item survey and semi-structured interviews on laparoscopic experience, knowledge, desires, barriers, patient perceptions, and training opportunities among surgeons and trainees at Liberia's two main teaching hospitals in March 2023. Data analysis utilized summed knowledge and desirability scores, descriptive statistics, and qualitative content analysis. RESULTS: 31 interns, residents, and consultants participated, comprising 60% of Liberia's surgeons. Laparoscopic training (32%) and experience (16%) was low, with exposure limited to those training outside Liberia (p = 0.001). While laparoscopy knowledge varied (29% low, 55% medium, 16% high), participants expressed high interest in training (100%) and willingness to pay (52%). Interviews revealed four themes: desires for training, patient acceptability, feasibility of technology-based training, and barriers including limited equipment and expert trainers. At the time of survey, the only minimally invasive surgeries ever performed in Liberia were two diagnostic laparoscopies. CONCLUSIONS: This is the first mixed-methods study assessing laparoscopy in Liberia. Our sample, though small, comprised approximately 60% of Liberian surgeons in both rural and urban hospitals. Findings demonstrated limited experience, variable knowledge, and high desires for training, showing feasibility for laparoscopy implementation in Liberia.

Effectiveness of Lay Bystander Hands-Only Cardiopulmonary Resuscitation on a Mattress versus the Floor: A Randomized Cross-Over Trial.

STUDY OBJECTIVE: Bystander cardiopulmonary resuscitation increases the likelihood of out-of-hospital cardiac arrest survival by more than two-fold. A common barrier to the prompt initiation of compressions is moving victims to the floor, but compression quality on a "floor" versus a "mattress" has not been tested among lay bystanders. METHODS: We conducted a prospective, randomized, cross-over trial comparing lay bystander compression quality using a manikin on a bed versus the floor. Participants included adults without professional health care training. We randomized participants to the order of manikin placement, either on a mattress or on the floor. For both, participants were instructed to perform 2 minutes of chest compressions on a cardiopulmonary resuscitation Simon manikin Gaumard (Gaumard Scientific, Miami, FL). The primary outcome was mean compression depth (cm) over 2 minutes. We fit a linear regression model adjusted for scenario order, age, sex, and body mass index with robust standard errors to account for repeated measures and reported mean differences with 95% confidence intervals (CIs). RESULTS: Our sample of 80 adults was 66% female with a mean age of 50.5 years (SD 18.2). The mean compression depth on the mattress was 2.9 cm (SD 2.3) and 3.5 cm (SD 2.2) on the floor, a mean difference of 0.58 cm (95% CI 0.18, 0.98). Compression depth fell below the 5 to 6 cm depth recommended by the American Heart Association on both surfaces. In the adjusted model, the mean depth was greater when the manikin was on the floor than the mattress (adjusted mean difference 0.62 cm; 95% CI 0.23 to 1.01), and mean depth was less for females than males (adjusted mean difference -1.42 cm, 95% CI -2.59, -0.25). In addition, the difference in compression depth was larger for female participants (mean difference 0.94 cm; 95% CI 0.54, 1.34) than for male participants (mean difference -0.01 cm; 95% CI -0.80, 0.78), and the interaction was statistically significant (P = .04). CONCLUSION: The mean compression depth was significantly smaller on the mattress and with female bystanders. Further research is needed to understand the benefit of moving out-of-hospital cardiac arrest victims to the floor relative to the detrimental effect of delaying chest compressions.

Evidence supporting performance measures of laparoscopic appendectomy through a novel surgical proficiency assessment tool and low-cost laparoscopic training system.

BACKGROUND: Laparoscopic training remains inaccessible for surgeons in low- and middle-income countries, limiting its widespread adoption. We developed a novel tool for assessment of laparoscopic appendectomy skills through ALL-SAFE, a low-cost laparoscopy training system. METHODS: This pilot study in Ethiopia, Cameroon, and the USA assessed appendectomy skills using the ALL-SAFE training system. Performance measures were captured using the ALL-SAFE verification of proficiency tool (APPY-VOP), consisting of a checklist, modified Objective Structured Assessment of Technical Skills (m-OSATS), and final rating. Twenty participants, including novice (n = 11), intermediate (n = 8), and expert (n = 1), completed an online module covering appendicitis management and psychomotor skills in laparoscopic appendectomy. After viewing an expert skills demonstration video, participants recorded their performance within ALL-SAFE. Using the APPY-VOP, participants rated their own and three peer videos. We used the Kruskal-Wallis test and a Many-Facet Rasch Model to evaluate (i) capacity of APPY-VOP to differentiate performance levels, (ii) correlation among three APPY-VOP components, and (iii) rating differences across groups. RESULTS: Checklist scores increased from novice (M = 21.02) to intermediate (M = 23.64) and expert (M = 28.25), with differentiation between experts and novices, P = 0.005. All five m-OSATS domains and global summed, total summed, and final rating discriminated across all performance levels (P < 0.001). APPY-VOP final ratings adequately discriminated Competent (M = 2.0), Borderline (N = 1.8), and Not Competent (M = 1.4) performances, Χ2 (2,85) = 32.3, P = 0.001. There was a positive correlation between ALL-SAFE checklist and m-OSATS summed scores, r(83) = 0.63, P < 0.001. Comparison of ratings suggested no differences across expertise levels (P = 0.69) or location (P = 0.66). CONCLUSION: APPY-VOP effectively discriminated between novice and expert performance in laparoscopic appendectomy skills in a simulated setting. Scoring alignment across raters suggests consistent evaluation, independent of expertise. These results support the use of APPY-VOP among all skill levels inside a peer rating system. Future studies will focus on correlating proficiency to clinical practice and scaling ALL-SAFE to other settings.

The Fundamentals of Vaginal Surgery pilot study: developing, validating, and setting proficiency scores for a vaginal surgical skills simulation system.

BACKGROUND: Surgical training in the simulation lab can develop basic skills that translate to the operating room. Standardized, basic skills programs that are supported by validated assessment measures exist for open, laparoscopic, and endoscopic surgery; however, there is yet to be a nationally recognized and widely implemented basic skills program specifically for vaginal surgery. OBJECTIVE: Develop a vaginal surgical simulation system; evaluate robust validity evidence for the simulation system and its related performance measures; and establish a proficiency score that discriminates between novice and experienced vaginal surgeon performance. STUDY DESIGN: In this 3-phased study, we developed the Fundamentals of Vaginal Surgery simulation system consisting of (1) the Fundamentals of Vaginal Surgery Trainer, a task trainer; (2) a validated regimen of tasks to be performed on the trainer; and (3) performance measures to determine proficiency. In Phase I, we developed the task trainer and selected surgical tasks by performing a needs assessment and hierarchical task analyses, with review and consensus from an expert panel. In Phase II, we conducted a national survey of vaginal surgeons to collect validity evidence regarding test content, response process, and internal structure relevant to the simulation system. In Phase III, we compared performance of novice (first and second year residents) and experienced (third and fourth year residents, fellows, and faculty) surgeons on the simulation system to evaluate relevant relationships to other variables and consequences. Performance measures were analyzed to set a proficiency score that would discriminate between novice and expert (faculty) vaginal surgical performance. RESULTS: A novel task trainer and 6 basic vaginal surgical skills were developed in Phase I. In Phase II, the survey responses of 48 participants (27 faculty surgeons, 6 fellows, and 14 residents) were evaluated on the dimensions of test content, response process, and internal structure. To support evidence of test content, the participants deemed the task trainer and surgical tasks representative of intended surgical field and supportive of typical surgical actions (mean scores, 3.8-4.4/5). For response process, rater-data analysis revealed high rating variability regarding prototype color. This early evidence confirmed the value of a white prototype. For internal structure, there was high agreement among rater groups (obstetricians and gynecologists generalists vs Female Pelvic Medicine and Reconstructive Surgery specialists: interclass correlation coefficient range, 0.59-0.91; learners vs faculty interclass correlation coefficient range, 0.64-1.0). There were no differences in ratings across institution type, surgeon volume, expertise (P>.14). In Phase III, we analyzed performance from 23 participants (15 [65%] obstetricians and gynecologists residents, 3 [13%] fellows, and 5 [22%] Female Pelvic Medicine and Reconstructive Surgery faculty). Experienced surgeons scored significantly higher than novice surgeons (median, 467.5; interquartile range, [402.5-542.5] vs median, 261.5; interquartile range, [211.5-351.0]; P<.001). Based on these data, setting a proficiency score threshold at 400 results in 0% (0/6) novices attaining the score, with 100% (5/5) experts exceeding it. CONCLUSION: We present validity evidence relevant to all 5 sources which supports the use of this novel simulation system for basic vaginal surgical skills. To complement the system, a proficiency score of 400 was established to discriminate between novices and experts.

Development and Multidisciplinary Preliminary Validation of a 3-Dimensional-Printed Pediatric Airway Model for Emergency Airway Front-of-Neck Access Procedures.

BACKGROUND: Pediatric-specific difficult airway guidelines include algorithms for 3 scenarios: unanticipated difficult tracheal intubation, difficult mask ventilation, and cannot intubate/cannot ventilate. While rare, these instances may require front-of-neck access (FONA) to secure an airway until a definitive airway can be established. The aim of this study was to develop a pediatric FONA simulator evaluated by both anesthesiology and otolaryngology providers, promoting multidisciplinary airway management. METHODS: A 3-dimensional-printed tracheal model was developed using rescaled, anatomically accurate dimensions from a computerized tomography scan using computer-aided design software. The medical grade silicone model was incorporated into a mannequin to create a low-cost, high-fidelity simulator. A multidisciplinary team of anesthesiology, otolaryngology, and simulation experts refined the model. Experts in airway management were recruited to rate the realism of the model's characteristics and features and their own ability to complete specific FONA-related tasks. RESULTS: Six expert raters (3 anesthesiology and 3 otolaryngology) were identified for multidisciplinary evaluation of model test content validity. Analysis of response data shows null variance within 1 or both specialties for a majority of the content validity tool elements. High and consistent absolute ratings for each domain indicate that the tested experts perceived this trainer as a realistic and highly valuable tool in its current state. CONCLUSIONS: The ability to practice front-of-neck emergency airway procedures safely and subsequently demonstrate proficiency on a child model has great implications regarding both quality of physician training and patient outcomes. This model may be incorporated into curricula to teach needle cricothyroidotomy and other FONA procedures to providers across disciplines.

Development and Validation of an Objective Scoring Tool for Robot-Assisted Radical Prostatectomy: Prostatectomy Assessment and Competency Evaluation.

PURPOSE: Comprehensive training and skill acquisition by urological surgeons are vital to optimize surgical outcomes and patient safety. We sought to develop and validate PACE (Prostatectomy Assessment and Competence Evaluation), an objective and procedure specific tool to assess the quality of robot-assisted radical prostatectomy. MATERIALS AND METHODS: Development and content validation of PACE was performed by deconstructing robot-assisted radical prostatectomy into 7 key domains utilizing the Delphi methodology. Reliability and construct validation were then assessed using de-identified videos performed by practicing surgeons and fellows. Consensus for each domain was defined as achieving a content validity index of 0.75 or greater. Reliability was assessed by the intraclass correlation and construct validation using a mixed linear model accounting for multiple ratings on the same video. RESULTS: After 3 rounds consensus was reached on wording, relevance of the skills assessed and concordance between the score assigned and the skill assessed. An intraclass correlation of 0.4 or greater was achieved for all domains. The expert group outperformed trainees in all domains but reached statistical significance in bladder drop (4.5 vs 3.4, p = 0.002), preparation of the prostate (4.4 vs 3.2, p <0.0001), seminal vesicle and posterior plane dissection (8.3 vs 6.8, p = 0.03), and neurovascular bundle preservation (4.1 vs 2.4, p <0.0001). Limitations included the lack of assessment of other key skills such as communication and decision making. CONCLUSIONS: PACE is a structured, procedure specific and reliable tool that objectively measures surgical performance during robot-assisted radical prostatectomy. It can differentiate different levels of expertise and provide structured feedback to customize training and surgical quality improvement.

Assessing anesthesiology residents' out-of-the-operating-room (OOOR) emergent airway management.

BACKGROUND: At many academic institutions, anesthesiology residents are responsible for managing emergent intubations outside of the operating room (OOOR), with complications estimated to be as high as 39%. In order to create an OOOR training curriculum, we evaluated residents' familiarity with the content and correct adherence to the American Society of Anesthesiologists' Difficult Airway Algorithm (ASA DAA). METHODS: Residents completed a pre-simulation multiple-choice survey measuring their understanding and use of the DAA. Residents then managed an emergent, difficult OOOR intubation in the simulation center, where two trained reviewers assessed performance using checklists. Post-simulation, the residents completed a survey rating their behaviors during the simulation. The primary outcome was comprehension and adherence to the DAA as assessed by survey responses and behavior in the simulation. RESULTS: Sixty-three residents completed both surveys and the simulation. Post-survey responses indicated a shift toward decreased self-perceived familiarity with the DAA content compared to pre-survey responses. During the simulation, 22 (35%) residents were unsuccessful with intubation. Of these, 46% placed an LMA and 46% prepared for cricothyroidotomy. Nineteen residents did not attempt intubation. Of these, only 31% considered LMA placement, and 26% initiated cricothyroidotomy. CONCLUSIONS: Many anesthesiology residency training programs permit resident autonomy in managing emergent intubations OOOR. Residents self-reported familiarity with the content of and adherence to the DAA was higher than that observed during the simulation. Curriculum focused on comprehension of the DAA, as well as improving communication with higher-level physicians and specialists, may improve outcomes during OOORs.

Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum.

ISSUE: Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents' rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor. EVIDENCE: A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm(3), and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) (n = 71). IMPLICATIONS: We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.

Integrating mental health specialty services via telehealth.

Older adults may experience a variety of mental health conditions that negatively impact quality of life and management of co-occurring medical conditions. Collaborative care models are an option to provide access to specialty mental health care; however, these programs are not widely accessible. We propose that the delivery of specialty care via telehealth is a cost effective solution to obstacles to care.

Infant bronchial tree simulator: Success of a built-from-scratch model for single lung isolation.

BACKGROUND: One-lung ventilation in infants is a high-risk procedure. Complications include endotracheal tube occlusion, with grave consequences. Although there are commercially available bronchoscopy simulators, there are no realistic models of infant patients. This limits access to training opportunities that would ensure safe and efficient lung isolation. To bridge this gap, we developesd a realistic infant bronchial tree model for single lung intubation and evaluated preliminary validity evidence of its features and clinicians' ability to perform critical skills associated with pediatric one-lung ventilation. METHODS: Using computed tomography imaging, a stereolithography file of an infant airway was generated to 3D print a model. This model was inserted into a commercially available airway trainer to allow lung isolation using standard bronchoscopy techniques. Ten experienced pediatric anesthesiologists independently evaluated the simulator's physical attributes, realism, value, and relevance using a 29-item paper survey and rated using 4-point rating scales (4 = highest). Participants' ability to complete 5 critical tasks was self-reported using 5-point rating scales (5 = too easy). Item and domain mean ratings were calculated, and comments reviewed. RESULTS: Overall, reviews were positive, with mean scores indicating adequate realism and high value. Specific challenges were associated with right mainstem bronchus and upper lobe takeoff. Performance scores indicated that most tasks were "somewhat easy to perform," suggesting that the model's anatomy did not hinder physicians' ability to perform one-lung ventilation. CONCLUSION: Preliminary findings indicate that the novel simulator holds promise for training in lung isolation techniques after refinement. Future research will target refinement, expanding evaluation, and developing a comprehensive curriculum and competency assessment program.

Multi-institutional beta testing of a novel cervical esophagogastric anastomosis simulator.

Objective: A novel simulator developed to offer hands-on practice for the stapled side-to-side cervical esophagogastric anastomosis was tested previously in a single-center study that supported its value in surgical education. This multi-institutional trial was undertaken to evaluate validity evidence from 6 independent thoracic surgery residency programs. Methods: After a virtual session for simulation leaders, learners viewed a narrated video of the procedure and then alternated as surgeon or first assistant. Using an online survey, perceived value was measured across fidelity domains: physical attributes, realism of materials, realism of experience, value, and relevance. Objective assessment included time, number of sutures tearing, bubble test, and direct inspection. Comparison across programs was performed using the Kruskal-Wallis test. Results: Surveys were completed by 63 participants as surgeons (17 junior and 20 senior residents, 18 fellows, and 8 faculty). For 3 of 5 tasks, mean ratings of 4.35 to 4.44 correlated with "somewhat easy" to "very easy" to perform. The interrupted outer layer of the anastomosis rated lowest, suggesting this task was the most difficult. The simulator was rated as a highly valuable training tool. For the objective measurements of performance, "direct inspection" rated highest followed by "time." A total of 90.5% of participants rated the simulator as ready for use with only minor improvements. Conclusions: Results from this multi-institutional study suggest the cervical esophagogastric anastomosis simulator is a useful adjunct for training and assessment. Further research is needed to determine its value in assessing competence for independent operating and associations between improved measured performance and clinical outcomes.

Using Artificial Intelligence to Gauge Competency on a Novel Laparoscopic Training System.

OBJECTIVE: Laparoscopic surgical skill assessment and machine learning are often inaccessible to low-and-middle-income countries (LMIC). Our team developed a low-cost laparoscopic training system to teach and assess psychomotor skills required in laparoscopic salpingostomy in LMICs. We performed video review using AI to assess global surgical techniques. The objective of this study was to assess the validity of artificial intelligence (AI) generated scoring measures of laparoscopic simulation videos by comparing the accuracy of AI results to human-generated scores. DESIGN: Seventy-four surgical simulation videos were collected and graded by human participants using a modified OSATS (Objective Structured Assessment of Technical Skills). The videos were then analyzed via AI using 3 different time and distance-based calculations of the laparoscopic instruments including path length, dimensionless jerk, and standard deviation of tool position. Predicted scores were generated using 5-fold cross validation and K-Nearest-Neighbors to train classifiers. SETTING: Surgical novices and experts from a variety of hospitals in Ethiopia, Cameroon, Kenya, and the United States contributed 74 laparoscopic salpingostomy simulation videos. RESULTS: Complete accuracy of AI compared to human assessment ranged from 65-77%. There were no statistical differences in rank mean scores for 3 domains, Flow of Operation, Respect for Tissue, and Economy of Motion, while there were significant differences in ratings for Instrument Handling, Overall Performance, and the total summed score of all 5 domains (Summed). Estimated effect sizes were all less than 0.11, indicating very small practical effect. Estimated intraclass correlation coefficient (ICC) of Summed was 0.72 indicating moderate correlation between AI and Human scores. CONCLUSIONS: Video review using AI technology of global characteristics was similar to that of human review in our laparoscopic training system. Machine learning may help fill an educational gap in LMICs where direct apprenticeship may not be feasible.

Early intranasal medication administration in out-of-hospital cardiac arrest: Two randomized simulation trials.

Objective: Intranasal medications have been proposed as adjuncts to out-of-hospital cardiac arrest (OHCA) care. We sought to quantify the effects of intranasal medication administration (INMA) in OHCA workflows. Methods: We conducted separate randomized OHCA simulation trials with lay rescuers (LRs) and first responders (FRs). Participants were randomized to groups performing hands-only cardiopulmonary resuscitation (CPR)/automated external defibrillator with or without INMA during the second analysis phase. Time to compression following the second shock (CPR2) was the primary outcome and compression quality (chest compression rate (CCR) and fraction (CCF)) was the secondary outcome. We fit linear regression models adjusted for CPR training in the LR group and service years in the FR group. Results: Among LRs, INMA was associated with a significant increase in CPR2 (mean diff. 44.1 s, 95% CI: 14.9, 73.3), which persisted after adjustment (p = 0.005). We observed a significant decrease in CCR (INMA 95.1 compressions per min (cpm) vs control 104.2 cpm, mean diff. -9.1 cpm, 95% CI -16.6, -1.6) and CCF (INMA 62.4% vs control 69.8%, mean diff. -7.5%, 95% CI -12.0, -2.9). Among FRs, we found no significant CPR2 delays (mean diff. -2.1 s, 95% CI -15.9, 11.7), which persisted after adjustment (p = 0.704), or difference in quality (CCR INMA 115.5 cpm vs control 120.8 cpm, mean diff. -5.3 cpm, 95% CI -12.6, 2.0; CCF INMA 79.6% vs control 81.2% mean diff. -1.6%, 95% CI -7.4, 4.3%). Conclusions: INMA in LR resuscitation was associated with diminished resuscitation performance. INMA by FR did not impede key times or quality.

Design and development of a novel thoracoscopic tracheoesophageal fistula repair simulator.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) is a technically challenging surgical procedure. This congenital anomaly is rare; therefore, training opportunities for surgical trainees are limited. There are currently no validated simulation tools available to help train pediatric surgery trainees. The simulator that was developed is a low-cost, reusable model. It simulates the right side of a term neonate chest and contains a tissue block that has been surgically modified to replicate the anatomy of EA/TEF.

Development and evaluation of a laparoscopic common bile duct exploration simulator and procedural rating scale.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE) is an effective, single-stage treatment for choledocholithiasis. However, LCBDE requires specific cognitive and technical skills, is infrequently performed by residents, and currently lacks suitable training and assessment modalities outside of the operating room. To address this gap in training, a simulator model for transcystic and transcholedochal LCBDE was developed and evaluated. METHODS: A procedure algorithm incorporating essential cognitive and technical steps of LCBDE was developed, along with a physical model to allow performance of a simulated procedure. Modified Objective Structured Assessment of Technical Skills (OSATS) rating scales were developed to assess performance on the model. Construct validity was assessed by comparing the performance of novices (residents and surgeons without LCBDE experience) versus experienced subjects (surgeons with previous LCBDE experience). Concurrent validity was assessed by comparing scores from the LCBDE scales to those from the standard OSATS scale. Internal consistency and interrater reliability were assessed by comparing performance scores assigned by three independent raters. RESULTS: Sixteen novices and five experienced subjects performed simulated procedures, with novices scoring lower than experienced subjects on both transcystic (20 ± 3 vs. 33 ± 2 [possible score range, 0-45], p < 0.001) and transcholedochal (25 ± 8 vs. 42 ± 3 [possible score range, 0-53], p < 0.001) rating scales. Scores on the rating scales correlated significantly with scores from the standard OSATS scale. Internal consistency and interrater reliability of the LCBDE rating scales were favorable. CONCLUSIONS: The LCBDE simulator is a low-cost yet realistic physical model that allows performance and evaluation of technical skills required for LCBDE. The LCBDE rating scales show evidence of construct validity, concurrent validity, internal consistency, and interrater reliability. Use of the LCBDE model and associated rating scales allows procedure-specific feedback for trainees and could be used to improve current training.

Use of mannequin-based simulation to decrease student anxiety prior to interacting with male teaching associates.

BACKGROUND: Previous studies have compared the usefulness of teaching associates versus mannequin trainers for learning physical exam skills. Little work has been done to assess the usefulness of mannequin trainers prior to students' interaction with teaching associates. PURPOSE: We studied the effects of mannequin-based simulators on student comfort levels toward learning the male genitourinary examination. METHODS: First-year medical students (N = 346) were surveyed before and after a mannequin-based curriculum to assess their comfort levels toward learning the male genitourinary examination. RESULTS: The mannequin-based curriculum significantly increased (p < .001) student comfort levels toward the male genitourinary exam. However, the pre-post improvements were small, and on average students only progressed from being "very uncomfortable" to "somewhat comfortable." The intimate nature of the examination was the top cause of anxiety toward learning the male genitourinary exam. Students were least comfortable with the digital rectal examination at the beginning of class. CONCLUSIONS: We suggest that mannequin-based simulators be used prior to students' experience with male teaching associates when learning the male genitourinary exam.

To Pack a Nose: High-Fidelity Epistaxis Simulation Using 3D Printing Technology.

BACKGROUND: Initial management and stabilization of epistaxis is managed by a diverse offset of clinical providers with variable levels of training. OBJECTIVE: To determine the anatomic and clinical fidelity and ease of use of a novel simulator for the training and assessment of epistaxis management skills. STUDY DESIGN: Qualitative Research Study using expert questionnaire's for validation of a newly developed simulator. METHODS: We performed a quasi-experimental intervention with 22 otolaryngology faculty and 10 trainees who independently evaluated the simulator. Data were collected in three phases: phase 1 (preliminary evaluation), phase 2 (final expert evaluation), and phase 3 (trainee evaluation). We designed a three-dimensional (3D) printed model from a de-identified patient computed tomography scan. Artificial blood was circulated through catheters to simulate bleeding from three distinct sites (sphenopalatine, Kiesselbach's plexus, and anterior ethmoid). Four domains were assessed: "Physical and anatomic attributes," "Realism of experience," "Ability to perform tasks," and "Value and clinical relevance." Internal structure and validity were measured with Cronbach's alpha and item outfit mean-square statistics. RESULTS: Results from otolaryngology faculty showed very high median ratings for "Value of the simulator as a training tool" (4.0/4) and high ratings for "Relevance to practice" (4.0/4), and realism of experience (4.0/4). Responses from otolaryngology trainees demonstrated high value for clinical training (4.0/4) and high likelihood to recommend use for future trainees (4.0/4). Confidence in managing epistaxis before (1.0/4) and after (3.0/4) simulator use was statistically improved (P = .03). CONCLUSIONS: Using 3D printing technology, we created a novel simulator for epistaxis management. Preliminary evidence suggests the model is cost-effective, anatomically realistic, relevant to trainees' educational needs, and valuable as a training tool. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:747-753, 2022.

Impact of the COVID-19 pandemic on American College of Surgeons-Accredited Education Institutes & American Society of Anesthesiologists-Simulation Education Network: Opportunities for interdisciplinary collaboration.

BACKGROUND: The COVID-19 pandemic presented challenges for simulation programs including American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network. American College of Surgeons Accredited Education Institutes and American Society of Anesthesiologists Simulation Education Network leadership were surveyed to identify opportunities to enhance patient safety through simulation. METHODS: Between January and June 2021, surveys consisting of 3 targeted domains: (I) Changing practice; (II) Contributions and recognition; and (III) Moving ahead were distributed to 100 American College of Surgeons Accredited Education Institutes and 54 American Society of Anesthesiologists Simulation Education Network centers. Responses were combined and percent frequencies reported. RESULTS: Ninety-six respondents, representing 51 (51%) American College of Surgeons Accredited Education Institutes, 17 (31.5%) American Society of Anesthesiologists Simulation Education Network, and 28 dually accredited centers, completed the survey. Change of practice. Although 20.3% of centers stayed fully operational at the COVID-19 onset, 82% of all centers closed: 32% were closed less than 3 months, 28% were closed 3 to 6 months, 8% were closed 7 to 9 months, and 32% remained closed as of June 6, 2021. Most impacted activities were large-group instruction and team training. Sixty-nine percent of programs converted in-person to virtual programs. Contributions. The top reported innovative contributions included policies (80%), curricula (80%), and scholarly work (74%), Moving ahead. The respondents' top concerns were returning to high-quality training to best address learners' deficiencies and re-engagement of re-directed training programs. When asked "How the American College of Surgeons/American Society of Anesthesiologists Programs could best assist your simulation center goals?" the top responses were "facilitate collaboration" and "publish best practices from this work." CONCLUSION: The Pandemic presented multiple challenges and opportunities for simulation centers. Opportunities included collaboration between American College of Surgeons Accredited Education Institutes and the American Society of Anesthesiologists Simulation Education Network to identify best practices and resources needed to enhance patient safety through simulation.

Meeting the New Joint Commission's Maternal Safety Requirements: A Quantitative Blood Loss Train-the-Trainer Program for Improved Process and Outcomes.

INTRODUCTION: Recently, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice encouraged the use of quantitative and cumulative assessment of maternal blood loss (QBL) as part of safety bundles for prevention of postpartum hemorrhage. The aim of this study was to determine whether our train-the-trainer QBL program improved process and patient outcomes. METHODS: In this pre-post interventional study, 26 "champions" participated in the QBL train-the-trainer program in preparation for patient safety bundle rollout. The multipart program included at least 3 simulated C-section hemorrhage scenarios and rapid-cycle debriefing. Champions used the curriculum for broad staff training for 2 months before safety bundle implementation.Six months each of preintervention and postintervention data were collected from medical records of all qualified cases (N = 4413). Process outcomes were evaluated by comparing number of women who received QBL. Patient outcomes were evaluated by comparing blood transfusion rates and number of morbid cases (≥4 packed red blood cell units). χ2 test was used for analyses. RESULTS: Review of medical records indicated that 99.8% of 2218 women received QBL posttraining compared with 16.6% of 2195 women receiving QBL before training (P = 0.0001.) Transfusion rates increased from 54.47 to 69.25 units/1000 mothers. The rate of morbid cases (≥4 red blood cell units) dropped from 2.13 to 0.48 cases/1000 mothers. CONCLUSIONS: Our findings suggest the train-the-trainer QBL program was associated with improved process and decreased morbidity when implemented with a hemorrhage safety bundle. Further research is required to examine components of simulation-based QBL training methods and implementation to evaluate their impact on clinical outcomes.

Learning and Collaboration during Crisis: A Novel University-Community Partnership to Manufacture Medical Personal Protective Equipment.

Research on crisis management focuses on pre-planning for disasters in order to understand potential barriers. However, one significant barrier to crisis response is that organizations may come together in unplanned configurations during crisis response. This means that significant opportunities exist for understanding the process by which individuals learn, collaborate, and create new systems during crises. In this case report, we present the case of face shield production by a university, academic medical center, and community partners during the supply chain collapse of the early COVID-19 pandemic with the aim of identifying the relationships that formed during the COVID-19 response, so that this case of relationship formation and participant experiences might inform similar disaster response challenges in the future. Thirteen participants responded to an in-depth questionnaire designed to simulate an asynchronous in-depth interview. Respondents reported on the activities of 80 individuals from 38 units/organizations, providing insight into communication challenges and resolutions. Responses were analyzed using thematic analysis, highlighting roles and relationships among participants. The findings grant insight into the experience of learning from crisis response efforts, responding to recent calls for social scientific work on COVID-19 responses.