Gastrointestinal Complications After Transesophageal Echocardiography for Mitral Valve Transcatheter Edge-to-Edge Repair: Insights From a Large Contemporary Cohort.

OBJECTIVES: Transesophageal echocardiography-related complications (TEE-RC) are higher in structural heart interventions than in traditional operative settings. In mitral valve transcatheter edge-to-edge repair (MV-TEER), the incidence of TEE-RC may be higher than in other structural interventions. However, existing reports are limited and robust data evaluating TEE safety in this patient population are lacking. The authors sought to describe the incidence and risk factors of upper gastrointestinal injuries after TEE in patients undergoing MV-TEER. DESIGN: A retrospective observational study. SETTING: A single tertiary academic hospital. PARTICIPANTS: A total of 442 consecutive patients who underwent MV-TEER, specifically with MitraClip, between December 2015 and March 2022. INTERVENTIONS: Transesophageal echocardiography was performed intraoperatively to guide all MV-TEERs. MEASUREMENTS AND MAIN RESULTS: The study's primary goal was to investigate an association between TEE procedure duration and TEE-RC risk. The contribution of demographic risk factors and intraprocedural characteristics also was investigated. Transesophageal echocardiography-RCs were observed in 17 out of 442 patients (3.8%). Dysphagia was the most common TEE-RC (n = 9/17, 53%), followed by new gastroesophageal reflux (n = 6/17, 35%) and odynophagia (n = 3/17, 18%). There were no esophageal perforations or upper gastrointestinal bleeds. History of dysphagia was the only variable associated with TEE-RCs (p = 0.008; n = 9 [2.1%] v n = 3 [18%]), with a relative risk of 8.67 (95% CI 2.57, 29.16). The TEE procedure duration was not statistically different between the 2 groups (46 minutes [39-64] in TEE-RCs v 49 minutes [36-77] in no complications). CONCLUSION: In patients undergoing MV-TEER, TEE-RCs are uncommon, and major complications are rare. The authors' outcomes reflect those of a high-volume referral center with TEEs performed by cardiac anesthesiologists.

Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training.

BACKGROUND: Operating room (OR) fires are rare but devastating events requiring immediate and effective response. Virtual Reality (VR) simulation training can provide a safe environment for practice of skills in such highly stressful situation. This study assessed interprofessional participants' ability to respond to VR-simulated OR fire scenarios, attitudes, numbers of attempt of the VR simulation do participants need to successfully respond to OR fires and does prior experience, confidence level, or professional role predict the number of attempts needed to demonstrate safety and pass the simulation. METHODS: 180 surgical team members volunteered to participate in this study at Beth Israel Deaconess Medical Center, Boston, MA. Each participant completed five VR OR simulation trials; the final two trials incorporated AI assistance. Primary outcomes were performance scores, number of attempts needed to pass, and pre- and post-survey results describing participant confidence and experiences. Differences across professional or training role were assessed using chi-square tests and analyses of variance. Differences in pass rates over time were assessed using repeated measures logistic regression. RESULTS: One hundred eighty participants completed simulation testing; 170 (94.4%) completed surveys. Participants included surgeons (17.2%), anesthesiologists (10.0%), allied health professionals (41.7%), and medical trainees (31.1%). Prior to training, 45.4% of participants reported feeling moderately or very confident in their ability to respond to an OR fire. Eight participants (4.4%) responded safely on the first simulation attempt. Forty-three participants (23.9%) passed by the third attempt (VR only); an additional 97 participants (53.9%) passed within the 4-5th attempt (VR with AI assistance). CONCLUSIONS: Providers are unprepared to respond to OR fires. VR-based simulation training provides a practical platform for individuals to improve their knowledge and performance in the management of OR fires with a 79% pass rate in our study. A VR AI approach to teaching this essential skill is innovative, feasible, and effective.

Preclinical Proficiency-Based Model of Ultrasound Training.

BACKGROUND: Graduate medical education is being transformed from a time-based training model to a competency-based training model. While the application of ultrasound in the perioperative arena has become an expected skill set for anesthesiologists, clinical exposure during training is intermittent and nongraduated without a structured program. We developed a formal structured perioperative ultrasound program to efficiently train first-year clinical anesthesia (CA-1) residents and evaluated its effectiveness quantitatively in the form of a proficiency index. METHODS: In this prospective study, a multimodal perioperative ultrasound training program spread over 3 months was designed by experts at an accredited anesthesiology residency program to train the CA-1 residents. The training model was based on self-learning through web-based modules and instructor-based learning by performing perioperative ultrasound techniques on simulators and live models. The effectiveness of the program was evaluated by comparing the CA-1 residents who completed the training to graduating third-year clinical anesthesia (CA-3) residents who underwent the traditional ultrasound training in the residency program using a designed index called a "proficiency index." The proficiency index was composed of scores on a cognitive knowledge test (20%) and scores on an objective structured clinical examination (OSCE) to evaluate the workflow understanding (40%) and psychomotor skills (40%). RESULTS: Sixteen CA-1 residents successfully completed the perioperative ultrasound training program and the subsequent evaluation with the proficiency index. The total duration of training was 60 hours of self-based learning and instructor-based learning. There was a significant improvement observed in the cognitive knowledge test scores for the CA-1 residents after the training program (pretest: 71% [0.141 ± 0.019]; posttest: 83% [0.165 ± 0.041]; P < .001). At the end of the program, the CA-1 residents achieved an average proficiency index that was not significantly different from the average proficiency index of graduating CA-3 residents who underwent traditional ultrasound training (CA-1: 0.803 ± 0.049; CA-3: 0.823 ± 0.063, P = .307). CONCLUSIONS: Our results suggest that the implementation of a formal, structured curriculum allows CA-1 residents to achieve a level of proficiency in perioperative ultrasound applications before clinical exposure.

Using Machine Learning to Evaluate Attending Feedback on Resident Performance.

BACKGROUND: High-quality and high-utility feedback allows for the development of improvement plans for trainees. The current manual assessment of the quality of this feedback is time consuming and subjective. We propose the use of machine learning to rapidly distinguish the quality of attending feedback on resident performance. METHODS: Using a preexisting databank of 1925 manually reviewed feedback comments from 4 anesthesiology residency programs, we trained machine learning models to predict whether comments contained 6 predefined feedback traits (actionable, behavior focused, detailed, negative feedback, professionalism/communication, and specific) and predict the utility score of the comment on a scale of 1-5. Comments with ≥4 feedback traits were classified as high-quality and comments with ≥4 utility scores were classified as high-utility; otherwise comments were considered low-quality or low-utility, respectively. We used RapidMiner Studio (RapidMiner, Inc, Boston, MA), a data science platform, to train, validate, and score performance of models. RESULTS: Models for predicting the presence of feedback traits had accuracies of 74.4%-82.2%. Predictions on utility category were 82.1% accurate, with 89.2% sensitivity, and 89.8% class precision for low-utility predictions. Predictions on quality category were 78.5% accurate, with 86.1% sensitivity, and 85.0% class precision for low-quality predictions. Fifteen to 20 hours were spent by a research assistant with no prior experience in machine learning to become familiar with software, create models, and review performance on predictions made. The program read data, applied models, and generated predictions within minutes. In contrast, a recent manual feedback scoring effort by an author took 15 hours to manually collate and score 200 comments during the course of 2 weeks. CONCLUSIONS: Harnessing the potential of machine learning allows for rapid assessment of attending feedback on resident performance. Using predictive models to rapidly screen for low-quality and low-utility feedback can aid programs in improving feedback provision, both globally and by individual faculty.

Less pain and earlier discharge after implementation of a multidisciplinary enhanced recovery after surgery (ERAS) protocol for laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) may be complicated by postoperative pain, nausea, and vomiting, with consequent increases in length of stay (LOS), decreased patient satisfaction, and higher costs. While enhanced recovery after surgery (ERAS) protocols have been in circulation for many years, there is no standard ERAS protocol for bariatric surgery. METHODS: Data were collected prospectively and compared to a historical control. All patients undergoing LSG, ages 18 to 75, were included in the pathway; those with preoperative chronic opioid use were excluded from our results. Statistical analysis was performed using t-statistics and chi-squared test. Ninety patients undergoing LSG, performed by a single surgeon, were included in our ERAS group from November 26, 2018, to April 30, 2019, and were compared to a historical control of 570 patients who underwent LSG over the previous 5 years (pre-ERAS). Measured outcomes included discharge opioid prescriptions issued, hospital length of stay, 30-day readmissions, reoperations, morbidity, and mortality. RESULTS: Ten (11%) ERAS patients vs 100% of pre-ERAS patients received opioid prescriptions upon, or after, discharge (p < 0.001). The ERAS group LOS decreased to 1.36 days vs 2.40 days in the pre-ERAS group (p < 0.001). 30-day readmission rates were 0% for ERAS patients vs 3.09% for pre-ERAS patients (p = 0.149). 30-day reoperation rates were 0% for ERAS patients vs 0.54% for pre-ERAS patients (p = 1). Thirty-day morbidity rates were 3.33% (3) for ERAS patients vs 3.27% for pre-ERAS patients (p = 1); there was no 30-day mortality in either group. CONCLUSION: ERAS for LSG results in a clinical and statistically significant reduction in postoperative opioid use and LOS, without increasing 30-day readmissions, reoperations, morbidity, or mortality.

Customizable Curriculum to Enhance Resident Communication Skills.

Communication remains challenging to teach and evaluate. We designed an online patient survey to assess anesthesia residents' communication skills from August 2014 to July 2015. In December 2014, we implemented a customized, simulation-based curriculum. We calculated an overall rating for each survey by averaging the ratings for the individual questions. Based on the Hodges-Lehmann 2-sample aligned rank-sum test, overall ratings, reported as the median (interquartile range) of residents' average overall ratings, differed significantly between the preintervention (3.86 [3.76-3.94]) and postintervention (3.91 [3.84-3.95]) periods (P = .025). Future studies should assess the intervention's effectiveness and generalizability.

Faculty-Focused Perioperative Ultrasound Training Program: A Single-Center Experience.

OBJECTIVE: Comprehensive educational initiatives in ultrasound for practicing physicians are lacking. We developed a perioperative ultrasound training program for faculty to offer a broad orientation to the principles and clinical applications of ultrasound. DESIGN AND SETTING: The program consisted of two phases. Phase one, which introduced ultrasound via didactic and hands-on components, had six live sessions. At the end of each, participants completed a knowledge quiz. During the sixth session, faculty participated in an objective structured clinical examination (OSCE). For phase two, faculty attended two to three sessions (8-10 hours each) of in-depth individualized training and demonstrated supervised performance of ultrasound-related procedures of their choice. PARTICIPANTS: Participants included Anesthesia faculty at Beth Israel Deaconess Medical Center. MEASUREMENTS AND MAIN RESULTS: On average 30 faculty members attended each live session for phase one; 12 completed phase two. There was a significant difference in quiz scores across the six sessions (p < 0.001) with scores for Session 6 being significantly higher than for Session 1 (p < 0.001). The average mean and median scores on the three OSCE stations were 95.63% and 98.33%, respectively. For phase two, the 8 participants who received training in regional anesthesia each performed > 10 blocks on patients over two days; 5 of the 7 participants who received training in transthoracic echocardiography each completed more than 15 examinations on simulators and 10 examinations on patients. CONCLUSION: It is possible to implement a departmental educational program for ultrasound to improve ultrasound knowledge and skills in practicing anesthesiologists.

Simulation-based Assessment to Reliably Identify Key Resident Performance Attributes.

BACKGROUND: Obtaining reliable and valid information on resident performance is critical to patient safety and training program improvement. The goals were to characterize important anesthesia resident performance gaps that are not typically evaluated, and to further validate scores from a multiscenario simulation-based assessment. METHODS: Seven high-fidelity scenarios reflecting core anesthesiology skills were administered to 51 first-year residents (CA-1s) and 16 third-year residents (CA-3s) from three residency programs. Twenty trained attending anesthesiologists rated resident performances using a seven-point behaviorally anchored rating scale for five domains: (1) formulate a clear plan, (2) modify the plan under changing conditions, (3) communicate effectively, (4) identify performance improvement opportunities, and (5) recognize limits. A second rater assessed 10% of encounters. Scores and variances for each domain, each scenario, and the total were compared. Low domain ratings (1, 2) were examined in detail. RESULTS: Interrater agreement was 0.76; reliability of the seven-scenario assessment was r = 0.70. CA-3s had a significantly higher average total score (4.9 ± 1.1 vs. 4.6 ± 1.1, P = 0.01, effect size = 0.33). CA-3s significantly outscored CA-1s for five of seven scenarios and domains 1, 2, and 3. CA-1s had a significantly higher proportion of worrisome ratings than CA-3s (chi-square = 24.1, P < 0.01, effect size = 1.50). Ninety-eight percent of residents rated the simulations more educational than an average day in the operating room. CONCLUSIONS: Sensitivity of the assessment to CA-1 versus CA-3 performance differences for most scenarios and domains supports validity. No differences, by experience level, were detected for two domains associated with reflective practice. Smaller score variances for CA-3s likely reflect a training effect; however, worrisome performance scores for both CA-1s and CA-3s suggest room for improvement.

Updated panel report: best practices for the surgical treatment of obesity.

BACKGROUND: During the 2004 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on best practices in bariatric surgery. The rapid evolution of endoluminal technologies, surgical indications, and training in bariatric surgery since 2004 has led to new questions and concerns about optimal treatment algorithms, patient selection, and the preparation of our current and future bariatric workforce. METHODS: An expert panel was convened at the SAGES 2017 annual meeting to provide a summative update on current practice patterns, techniques, and training in bariatric surgery in order to review and establish best practices. This was a joint effort by SAGES, International Society for the Perioperative Care of the Obese Patient, and the American Society for Metabolic and Bariatric Surgery. RESULTS: On March 23, 2017, seven expert faculty convened to address current areas of controversy in bariatric surgery and provide updated guidelines and practice recommendations. Areas addressed included the expanded indications for use of metabolic surgery in the treatment of diabetes, the safety and efficacy of new and investigational endoluminal procedures, updates on new guidelines for the management of airway and sleep apnea in the obese patient, the development of clinical pathways to reduce variation in the management of the bariatric patient, and new guidelines for training, credentialing, and bariatric program accreditation. The following article is a summary of this panel. CONCLUSION: Bariatric surgery is a field that continues to evolve. A timely, systematic approach, such as described here, that coalesces data and establishes best practices on the current body of available evidence is imperative for optimal patient care and to inform provider, insurer, and policy decisions.

Summative Objective Structured Clinical Examination Assessment at the End of Anesthesia Residency for Perioperative Ultrasound.

While standardized examinations and data from simulators and phantom models can assess knowledge and manual skills for ultrasound, an Objective Structured Clinical Examination (OSCE) could assess workflow understanding. We recruited 8 experts to develop an OSCE to assess workflow understanding in perioperative ultrasound. The experts used a binary grading system to score 19 graduating anesthesia residents at 6 stations. Overall average performance was 86.2%, and 3 stations had an acceptable internal reliability (Kuder-Richardson formula 20 coefficient >0.5). After refinement, this OSCE can be combined with standardized examinations and data from simulators and phantom models to assess proficiency in ultrasound.

OR fire virtual training simulator: design and face validity.

BACKGROUND: The Virtual Electrosurgical Skill Trainer is a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees, practicing surgeons, anesthesiologist, and nurses to interact with a virtual OR environment, which includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head-mounted display, participants must correctly identify the "fire triangle" elements and then successfully contain an OR fire. Within these virtual reality scenarios, trainees learn to react appropriately to the simulated emergency. A study targeted at establishing the face validity of the virtual OR fire simulator was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons conference. METHODS: Forty-nine subjects with varying experience participated in this Institutional Review Board-approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. Subjects were then asked to answer a subjective preference questionnaire consisting of sixteen questions, focused on the usefulness and fidelity of the simulator. RESULTS: On a 5-point scale, 12 of 13 questions were rated at a mean of 3 or greater (92%). Five questions were rated above 4 (38%), particularly those focusing on the simulator effectiveness and its usefulness in OR fire safety training. A total of 33 of the 49 participants (67%) chose the virtual OR fire trainer over the traditional training methods such as a textbook or an animal model. CONCLUSIONS: Training for OR fire emergencies in fully immersive VR environments, such as the VEST trainer, may be the ideal training modality. The face validity of the OR fire training module of the VEST simulator was successfully established on many aspects of the simulation.

Enhancing Feedback on Professionalism and Communication Skills in Anesthesia Residency Programs.

BACKGROUND: Despite its importance, training faculty to provide feedback to residents remains challenging. We hypothesized that, overall, at 4 institutions, a faculty development program on providing feedback on professionalism and communication skills would lead to (1) an improvement in the quantity, quality, and utility of feedback and (2) an increase in feedback containing negative/constructive feedback and pertaining to professionalism/communication. As secondary analyses, we explored these outcomes at the individual institutions. METHODS: In this prospective cohort study (October 2013 to July 2014), we implemented a video-based educational program on feedback at 4 institutions. Feedback records from 3 months before to 3 months after the intervention were rated for quality (0-5), utility (0-5), and whether they had negative/constructive feedback and/or were related to professionalism/communication. Feedback records during the preintervention, intervention, and postintervention periods were compared using the Kruskal-Wallis and χ tests. Data are reported as median (interquartile range) or proportion/percentage. RESULTS: A total of 1926 feedback records were rated. The institutions overall did not have a significant difference in feedback quantity (preintervention: 855/3046 [28.1%]; postintervention: 896/3327 [26.9%]; odds ratio: 1.06; 95% confidence interval, 0.95-1.18; P = .31), feedback quality (preintervention: 2 [1-4]; intervention: 2 [1-4]; postintervention: 2 [1-4]; P = .90), feedback utility (preintervention: 1 [1-3]; intervention: 2 [1-3]; postintervention: 1 [1-2]; P = .61), or percentage of feedback records containing negative/constructive feedback (preintervention: 27%; intervention: 32%; postintervention: 25%; P = .12) or related to professionalism/communication (preintervention: 23%; intervention: 33%; postintervention: 24%; P = .03). Institution 1 had a significant difference in feedback quality (preintervention: 2 [1-3]; intervention: 3 [2-4]; postintervention: 3 [2-4]; P = .001) and utility (preintervention: 1 [1-3]; intervention: 2 [1-3]; postintervention: 2 [1-4]; P = .008). Institution 3 had a significant difference in the percentage of feedback records containing negative/constructive feedback (preintervention: 16%; intervention: 28%; postintervention: 17%; P = .02). Institution 2 had a significant difference in the percentage of feedback records related to professionalism/communication (preintervention: 26%; intervention: 57%; postintervention: 31%; P < .001). CONCLUSIONS: We detected no overall changes but did detect different changes at each institution despite the identical intervention. The intervention may be more effective with new faculty and/or smaller discussion sessions. Future steps include refining the rating system, exploring ways to sustain changes, and investigating other factors contributing to feedback quality and utility.

Assessment of Perioperative Ultrasound Workflow Understanding: A Consensus.

OBJECTIVES: Understanding of the workflow of perioperative ultrasound (US) examination is an integral component of proficiency. Workflow consists of the practical steps prior to executing an US examination (eg, equipment operation). Whereas other proficiency components (ie, cognitive knowledge and manual dexterity) can be tested, workflow understanding is difficult to define and assess due to its contextual and institution-specific nature. The objective was to define the workflow components of specific perioperative US applications using an iterative process to reach a consensus opinion. DESIGN: Expert consensus, survey study. SETTING: Tertiary university hospital. PARTICIPANTS: This study sought expert consensus among a focus group of 9 members of an anesthesia department with experience in perioperative US. Afterward, 257 anesthesia faculty members from 133 academic centers across the United States were surveyed. INTERVENTIONS: A preliminary list of tasks was designed to establish the expectations of workflow understanding by an anesthesiology resident prior to clinical exposure to perioperative US. This list was modified by a focus group through an iterative process. Afterwards, a survey was sent to faculty members nationwide, and Likert scale ratings for each task were obtained and reviewed during a second round. MEASUREMENTS AND MAIN RESULTS: Consensus among members of the focus group was reached after 2 iterations. 72 participants responded to the nationwide survey (28%), and consensus was reached after the second round (Cronbach's α = 0.99, ICC = 0.99) on a final list of 46 workflow-related tasks. CONCLUSIONS: Specific components of perioperative US workflow were identified. Evaluation of workflow understanding may be combined with cognitive knowledge and manual dexterity testing for assessing proficiency in perioperative US.

Face validation of the Virtual Electrosurgery Skill Trainer (VEST©).

BACKGROUND: Electrosurgery is a modality that is widely used in surgery, whose use has resulted in injuries, OR fires and even death. The SAGES has established the FUSE program to address the knowledge gap in the proper and safe usage of electrosurgical devices. Complementing it, we have developed the Virtual Electrosurgery Skill Trainer (VEST(©)), which is designed to train subjects in both cognitive and motor skills necessary to safely operate electrosurgical devices. The objective of this study is to asses the face validity of the VEST(©) simulator. METHODS: Sixty-three subjects were recruited at the 2014 SAGES Learning Center. They all completed the monopolar electrosurgery module on the VEST(©) simulator. At the end of the study, subjects assessed the face validity with questions that were scored on a 5-point Likert scale. RESULTS: The subjects were divided into two groups; FUSE experience (n = 15) and no FUSE experience (n = 48). The median score for both the groups was 4 or higher on all questions and 5 on questions on effectiveness of VEST(©) in aiding learning electrosurgery fundamentals. Questions on using the simulator in their own skills lab and recommending it to their peers also scored at 5. Mann-Whitney U test showed no significant difference (p > 0.05) indicating a general agreement. 46% of the respondents preferred VEST compared with 52% who preferred animal model and 2% preferred both for training in electrosurgery. CONCLUSION: This study demonstrated the face validity of the VEST(©) simulator. High scores showed that the simulator was visually realistic and reproduced lifelike tissue effects and the features were adequate enough to provide high realism. The self-learning instructional material was also found to be very useful in learning the fundamentals of electrosurgery. Adding more modules would increase the applicability of the VEST(©) simulator.

Face and construct validation of a next generation virtual reality (Gen2-VR) surgical simulator.

INTRODUCTION: Surgical performance is affected by distractors and interruptions to surgical workflow that exist in the operating room. However, traditional surgical simulators are used to train surgeons in a skills laboratory that does not recreate these conditions. To overcome this limitation, we have developed a novel, immersive virtual reality (Gen2-VR) system to train surgeons in these environments. This study was to establish face and construct validity of our system. METHODS AND PROCEDURES: The study was a within-subjects design, with subjects repeating a virtual peg transfer task under three different conditions: Case I: traditional VR; Case II: Gen2-VR with no distractions and Case III: Gen2-VR with distractions and interruptions. In Case III, to simulate the effects of distractions and interruptions, music was played intermittently, the camera lens was fogged for 10 s and tools malfunctioned for 15 s at random points in time during the simulation. At the completion of the study subjects filled in a 5-point Likert scale feedback questionnaire. A total of sixteen subjects participated in this study. RESULTS: Friedman test showed significant difference in scores between the three conditions (p < 0.0001). Post hoc analysis using Wilcoxon signed-rank tests with Bonferroni correction further showed that all the three conditions were significantly different from each other (Case I, Case II, p < 0.0001), (Case I, Case III, p < 0.0001) and (Case II, Case III, p = 0.009). Subjects rated that fog (mean 4.18) and tool malfunction (median 4.56) significantly hindered their performance. CONCLUSION: The results showed that Gen2-VR simulator has both face and construct validity and that it can accurately and realistically present distractions and interruptions in a simulated OR, in spite of limitations of the current HMD hardware technology.

Fundamental Use of Surgical Energy (FUSE) certification: validation and predictors of success.

INTRODUCTION: The Fundamental Use of Surgical Energy (FUSE) program includes a Web-based didactic curriculum and a high-stakes multiple-choice question examination with the goal to provide certification of knowledge on the safe use of surgical energy-based devices. The purpose of this study was (1) to set a passing score through a psychometrically sound process and (2) to determine what pretest factors predicted passing the FUSE examination. METHODS: Beta-testing of multiple-choice questions on 62 topics of importance to the safe use of surgical energy-based devices was performed. Eligible test takers were physicians with a minimum of 1 year of surgical training who were recruited by FUSE task force members. A pretest survey collected baseline information. RESULTS: A total of 227 individuals completed the FUSE beta-test, and 208 completed the pretest survey. The passing/cut score for the first test form of the FUSE multiple-choice examination was determined using the modified Angoff methodology and for the second test form was determined using a linear equating methodology. The overall passing rate across the two examination forms was 81.5%. Self-reported time studying the FUSE Web-based curriculum for a minimum of >2 h was associated with a passing examination score (p < 0.001). Performance was not different based on increased years of surgical practice (p = 0.363), self-reported expertise on one or more types of energy-based devices (p = 0.683), participation in the FUSE postgraduate course (p = 0.426), or having reviewed the FUSE manual (p = 0.428). Logistic regression found that studying the FUSE didactics for >2 h predicted a passing score (OR 3.61; 95% CI 1.44-9.05; p = 0.006) independent of the other baseline characteristics recorded. CONCLUSION(S): The development of the FUSE examination, including the passing score, followed a psychometrically sound process. Self-reported time studying the FUSE curriculum predicted a passing score independent of other pretest characteristics such as years in practice and self-reported expertise.

Validation of a Virtual Simulator With Haptic Feedback for Endotracheal Intubation Training.

INTRODUCTION: Endotracheal intubation (ETI) is a procedure that varies in difficulty because of patient characteristics and clinical conditions. Existing physical simulators do not encompass these variations. The Virtual Airway Skills Trainer for Endotracheal Intubation (VAST-ETI) was developed to provide different patient characteristics and high-fidelity haptic feedback to improve training. METHODS: We demonstrate the effectiveness of VAST-ETI as a training and evaluation tool for ETI. Construct validation was evaluated by scoring the performance of experts ( N = 15) and novices ( N = 15) on the simulator to ensure its ability to distinguish technical proficiency. Convergent and predictive validity were evaluated by performing a learning curve study, in which a group of novices ( N = 7) were trained for 2 weeks using VAST-ETI and then compared with a control group ( N = 9). RESULTS: The VAST-ETI was able to distinguish between expert and novice based on mean simulator scores ( t [88] = -6.61, P < 0.0005). When used during repeated practice, individuals demonstrated a significant increase in their score on VAST-ETI over the learning period ( F [11,220] = 7206, P < 0.001); however when compared with a control group, there was not a significant interaction effect on the simulator score. There was a significant difference between the simulator-trained and control groups ( t [12.85] = -2.258, P = 0.042) when tested in the operating room. CONCLUSIONS: Our results demonstrate the effectiveness of virtual simulation with haptic feedback for assessing performance and training of ETI. The simulator was not able to differentiate performance between more experienced trainees and experts because of limits in simulator difficulty.

Rationale for the fundamental use of surgical Energy™ (FUSE) curriculum assessment: focus on safety.

BACKGROUND: Almost all surgical procedures involve the use of devices that apply energy to tissue. Adverse events can occur if the devices are not used appropriately. The SAGES' Fundamental Use of Surgical Energy™ (FUSE) program will include a curriculum and certification examination to address this safety issue. The aim of this study was to determine the self-perceived knowledge of practicing surgeons related to energy-based devices and identify areas to emphasize in the assessment component of FUSE. METHODS: Psychometric experts led the test development process. During a 2-day retreat, a multidisciplinary group defined 63 test objectives assessing the knowledge and skills required to use energy-based surgical instruments safely (job task analysis). A survey was sent to a sample of 103 SAGES leaders and others in the test target audience to determine the number of items to use for the certification examination. Participants rated each objective for frequency, relevance, and importance on a 1-7 scale with the means used to create a weighted scale. The survey also included five self-assessment questions. RESULTS: Fifty surveys were completed; only 28 % of respondents considered themselves "experts." The most common source of knowledge was "industry sales representative or course" (42 %). The highest weighted topic was "Prevention of Adverse Events with Electrosurgery." The highest-rated objectives (>6 out of 7) were "Identify various mechanisms whereby electrosurgical injuries may occur," "Identify patient protection measures for setup and settings for the electrosurgical unit," and "Identify circumstances, mechanisms, and prevention of dispersive electrodes-related injury." CONCLUSIONS: Although basic and advanced energy-based devices are commonly used, training has been largely dependent upon industry representatives or industry-sponsored courses. Few surgeons consider themselves experts in the mechanisms of action and the appropriate and safe use of energy-based surgical devices. Competencies that emphasize electrosurgical safety were viewed as most important for the FUSE certification examination.