Ambulatory surgery centres: a potential solution to a chronic problem.

SummaryLong wait times for elective surgery in Canada have been a persistent problem for many years and the recent pandemic has made the situation substantially worse. Current evidence suggests that ambulatory surgery centres are more cost-effective and efficient in the delivery of ambulatory surgical services than larger institutions. We explore the merits of a network of publicly funded ambulatory surgery centres.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury.

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

"It's Only Brain Surgery": Using 3D Printing and Simulation to Prepare Rural Physicians for the Management of Acute Epidural Hematoma.

Patients presenting to rural emergency departments with increased intracranial pressure (ICP) can be challenging to diagnose, manage, and treat and although the presentation is rare, it is associated with high morbidity and mortality. In areas such as Newfoundland and Labrador, Canada, where the majority of the province is located far from tertiary care, this problem can be compounded by adverse weather impeding transport, necessitating that the problem is handled by rural physicians instead of neurosurgical care. However, many rural medical personnel do not receive any formal training in treating increased ICP. In this technical report, we use a low-tech, low-cost, high fidelity 3D printed skull to outline a simulation of increased ICP to better prepare rural physicians and emergency department teams who may encounter such a scenario in their practice in a rural area.

Development of a Three-dimensional Printed Emergent Burr Hole and Craniotomy Simulator.

Patients with a traumatic head injury (THI) require immediate surgical intervention, as rapidly expanding intracranial hematomas can be imminently life-threatening, not permitting transfer time to neurosurgical care in a tertiary care center. In rural and remote areas, where neurosurgeons may not be readily available, surgical intervention by Community General Surgeons (CGS) may be required. Currently, the CGS in Newfoundland and Labrador (NL) do not have access to, or have experience training with, an emergent burr hole/craniotomy (EBHC) simulator. One of the barriers is the availability of inexpensive and reliable simulators to practice these skills. Therefore, a low-cost, three-dimensional (3D) printed EBHC simulator was designed and 3D-printed by MUN Med 3D (St John's, NL). The aim of this technical report is to assess the need for such simulator in rural and remote healthcare centers and report on the iterative development of the EBHC simulator. The 3D-printed EBHC simulator developed by MUN Med 3D was utilized during a general surgery workshop at the 26th Annual Rural and Remote Medicine Conference in St. John's, NL. A total of six 3D-printed EBHC simulators were provided for the hour and a half workshop. At the end of the workshop, 16 participants were asked to provide feedback on the need for this simulator in their rural or remote environment as well as feedback on the physical attributes. The feedback received from the participants was overall positive, informative, and supported the need for the 3D-printed EBHC simulator.

TEAM: A Low-Cost Alternative to ATLS for Providing Trauma Care Teaching in Haiti.

OBJECTIVE: Trauma resuscitation protocols have unified the care of trauma patients and significantly improved outcomes. However, the success of the Advanced Trauma Life Support course is difficult to reproduce in developing countries due to set-up costs, limitations of resources, and variations of practice. The objective of this study is to assess the Trauma Evaluation and Management (TEAM) course as a low-cost alternative for trauma resuscitation teaching in Low and Middle Income Countries (LMIC). DESIGN: As part of the Team Broken Earth initiative, TEAM course was provided to the health care professionals in Haiti. At its conclusion, participants were asked to complete a survey evaluating the course. Qualitative and quantitative data were analyzed to evaluate the perception of the course. SETTING: The course was provided in Port-au-Prince, Haiti. PARTICIPANTS: A total of 80 health care professionals participated in the course. Response was obtained from 69 participants, which comprised of 32 physicians, 10 Emergency Medical Technicians (EMT), 22 nurses, and 5 medical trainees. RESULTS: The course was well received by physicians, nurses, and EMT with an average score of 90.6%. Question analysis revealed a lower satisfaction of physicians for the course manual and teaching materials, and information related to decisions for transfer of patients. EMT consistently felt that the course was not tailored to their learning and practice needs. Written feedback demonstrated several areas of weaknesses including need for improvements in translations, hands-on practice, and educational materials. CONCLUSIONS: Overall, the TEAM course was well received. Analysis demonstrated a need for adjustments specific to LMIC including a focus on prehospital assessment, increased nursing responsibilities, and unavailability of specialist's referrals. Team Broken Earth intends to take these findings into consideration and continue to provide the TEAM course to other LMIC.

Preoperative and Postoperative Assessments of Biochemical Parameters in Patients with Severe Obesity Undergoing Laparoscopic Sleeve Gastrectomy.

BACKGROUND: The study aim was to determine the prevalence of abnormal serum biochemistries associated with micronutrient deficiencies before and after laparoscopic sleeve gastrectomy (LSG). METHODS: Two hundred and one patients had LSG surgery between May 2011 and May 2014. Using a prospective cohort study design, data were collected on ferritin, hemoglobin (Hgb), mean cell volume (MCV), calcium, albumin, 25-hydroxyvitamin D (25-OH-D), PTH, and vitamin B12 with follow-up of 75.6% (n = 152), 63.7% (n = 128), 52.7% (n = 106), and 40.3% (n = 81) at 6, 12, 18, and 24 months, respectively. RESULTS: Patients were female (81.6%) with mean ± SD, BMI (48.8 ± 6.8 kg/m2), weight (135.1 ± 23.6 kg), and age (44.0 ± 9.6 years). Mean values for all biochemical parameters pre- and post-LSG were within reference limits. After adjusting for age, weight, and supplement use, trend tests post-LSG were significant for mean differences in ferritin (p = 0.002), calcium (p = 0.017), and vitamin B12 (p = 0.034). Pre-LSG, the proportion of patients with values below reference limits included 25-OH-D (20.4%), ferritin (12.3%), and Hgb (10.0%), while the proportion above reference limits included PTH (29.1%) and ferritin (17.4%). After adjustment, hypoalbuminemia was more prevalent after 1 year; the proportion of patients with PTH levels in the upper reference limit was higher 6 months post-LSG (p < 0.05). Multivitamin use increased presurgery from 44 to 88% 2 years postsurgery. Vitamin B12 supplementation increased from 7% before surgery to 32% 2 years postsurgery. CONCLUSION: Abnormal serum biochemistries indicative of micronutrient deficiencies were prevalent before surgery; reduced abnormal values were observed after surgery, likely due to an increased use of multivitamins.

Pre-operative and post-operative changes in CRP and other biomarkers sensitive to inflammatory status in patients with severe obesity undergoing laparoscopic sleeve gastrectomy.

INTRODUCTION: C-reactive protein (CRP) is often elevated in patients living with severe obesity (BMI≥35kg/m2). However, there is limited information on how CRP, and other inflammation responsive biomarkers, change in response to weight loss following laparoscopic sleeve gastrectomy (LSG). We studied how CRP, ferritin and albumin change following LSG surgery in relation to obesity, metabolic syndrome (MetS) ATPIII risk components and diabetes mellitus (DM). METHODS: Laboratory parameters (including CRP) were examined in 197 patients prior to LSG, and at 6, 12, 18 and 24months. Changes in laboratory parameters, and laboratory investigations, were also examined in a 125 patient subgroup at both pre-LSG and at the 12month follow-up visit. RESULTS: All patients had BMI≥35kg/m2. CRP levels positively correlated with BMI (r=0.171, p=0.016) and alkaline phosphatase (ALP; r=0.309; P<0.001), but negatively correlated with alanine aminotransferase (ALT; r=-0.260; P<0.001) and albumin (r=-0.358; P<0.001). LSG significantly reduced CRP and ferritin, which were maintained for at least 24months. At 12months post-LSG there was a significant decrease in weight (kgs) (p<0.001), CRP (p<0.001), ferritin (p=0.004), and various MetS risk components (p<0.001) but not albumin (p=0.057). Changes in CRP also correlated with changes in weight (r=0.233, p=0.018) and ALP (r=0.208, p=0.034) but not albumin (r=-0.186, p=0.058) or ferritin (r=0.160, p=0.113) after LSG. CONCLUSION: The negative correlation between CRP and albumin levels in obesity may indicate a low grade inflammatory process affecting both. LSG related weight loss decreased CRP and ferritin, likely explained by improvement in inflammatory status.

The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks.

BACKGROUND: Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure's morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. METHODS: We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. RESULTS: Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was $35 000. CONCLUSION: The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.

CONTEXTE: Même si la gastrectomie longitudinale par laparoscopie (GLL) s'est révélée sûre et efficace pour le traitement de l'obésité sévère (indice de masse corporelle ≥ 35), les fuites survenant à la ligne d'agrafes demeurent une complication majeure et sont responsables d'une bonne partie des complications et des décès associés à cette chirurgie. Plusieurs des centres effectuant des GLL procèdent au dépistage systématique des fuites à la ligne d'agrafes en réalisant des tests avec des agents de contraste le jour suivant la chirurgie. Nous avons évalué l'utilité du test à la gastrografine comme méthode de dépistage précoce des fuites à la ligne d'agrafes au jour 1, ainsi que les coûts qui y sont associés. MÉTHODES: Nous avons mené une étude rétrospective à partir d'une base de données créée de façon prospective qui portait sur 200 patients ayant subi une GLL entre 2011 et 2014 en raison d'une obésité sévère. Les principaux indicateurs de résultats étaient l'incidence de fuites à la ligne d'agrafes et les résultats obtenus aux tests à la gastrografine. Les renseignements sur le coût des tests d'imagerie nous ont été fournis par les départements appropriés des hôpitaux. RÉSULTATS: Selon les résultats des tests à la gastrografine au jour 1 obtenus pour les 200 patients ayant subi une GLL, 3 patients (1,5 %) présentaient des fuites à la ligne d'agrafes. Il s'agissait en réalité d'un vrai positif et 2 faux négatifs. Le diagnostic des faux négatifs a ensuite été effectué par tomographie par ordinateur. La sensibilité du test à la gastrografine était donc de 33 % au cours de cette étude. Le coût total de ce test, pour les 200 patients, était de 35 000 $. CONCLUSION: Le recours à des examens systématiques du tractus gastro-intestinal supérieur au moyen d'agents de contraste pour le dépistage précoce des fuites à la ligne d'agrafes a une faible sensibilité et est associé à des coûts élevés. Nous recommandons plutôt l'utilisation sélective de la tomographie par ordinateur.

The Newfoundland and Labrador Bariatric Surgery Cohort Study: Rational and Study Protocol.

BACKGROUND: In Canada, there has been a disproportionate increase in adults with Class II (BMI 35.0-39.9 kg/m2) or Class III obesity (BMI ≥ 40 kg/m2) affecting 9 % of Canadians with increases projected. Individuals affected by severe obesity (BMI ≥ 35) are at increased risk of high blood pressure, cardiovascular disease, diabetes, cancer, impaired quality of life, and premature mortality. Bariatric surgery is the most effective treatment for severe obesity. Laparoscopic sleeve gastrectomy (LSG), a relatively new type of bariatric surgery, is growing in popularity as a treatment. The global prevalence of LSG increased from 0 to 37.0 % between 2003 and 2013. In Canada and the US, between 2011 and 2013, the number of LSG surgeries increased by 244 % and LSG now comprises 43 % of all bariatric surgeries. Since 2011, Eastern Health, the largest regional health authority in Newfoundland and Labrador (NL), Canada has performed approximately 100 LSG surgeries annually. METHODS: A population-based prospective cohort study with pre and post surgical assessments at 1, 3, 6, 12, 18, 24 months and annually thereafter of patients undergoing LSG. This study will report on short - to mid-term (2-4 years) outcomes. Patients (n = 200) followed by the Provincial Bariatric Surgery Program between 19 and 70 years of age, with a BMI between 35.0 and 39.9 kg/m2 and an obesity-related comorbidity or with a BMI ≥ 40 kg/m2 are enrolled. The study is assessing the following outcomes: 1) complications of surgery including impact on nutritional status 2) weight loss/regain 3) improvement/resolution of comorbid conditions and a reduction in prescribed medications 4) patient reported outcomes using validated quality of life tools, and 5) impact of surgery on health services use and costs. We hypothesize a low complication rate, a marked reduction in weight, improvement/resolution of comorbid conditions, a reduction in related medications, improvement in quality of life, and a decrease in direct healthcare use and costs and indirect costs compared to pre-surgery. DISCUSSION: Limited data on the impact of LSG as a stand-alone procedure on a number of outcomes exist. The findings from this study will help to inform evidence-based practice, clinical decision-making, and the development of health policy.

Effect of Colonoscopy Volume on Quality Indicators.

Background. The purpose of this study is to determine if colonoscopy quality is associated with the annual case volume of endoscopists. Methods. A retrospective cohort study was performed on 3235 patients who underwent colonoscopy in the city of St. John's, NL, between January and June 2012. Data collected included completion of colonoscopy (CCR) and adenoma detection rates (ADR). Endoscopists were divided into quintiles based on annual case volume. To account for potential confounding variables, univariate analyses followed by multivariable logistic regression were used to identify variables independently associated with CCR and ADR. Results. A total of 13 surgeons and 8 gastroenterologists were studied. There was a significant difference in CCR (p < 0.001) and ADR (p < 0.001) based on annual volume. Following multivariable regression, predictors of successful colonoscopy completion included annual colonoscopy volume, lower age, male sex, an indication of screening or surveillance, and a low ASA score. Predictors of adenoma detection included older age, male sex, an indication of screening or surveillance, and gastroenterology specialty. Conclusion. Higher annual case volume is associated with better quality of colonoscopy in terms of completion. However, gastroenterology specialty appears to be a better predictor of ADR than annual case volume.

Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien-Dindo classification.

BACKGROUND: Newfoundland and Labrador (NL) has the highest rate of obesity in Canada, prompting the establishment of a bariatric surgery program at the Health Sciences Centre in NL. This retrospective study examined 30-day complication rates in more than 200 consecutive patients who underwent laparoscopic sleeve gastrectomy (LSG) between May 2011 and February 2014. METHODS: We performed a chart review and collected data on 30-day postoperative complications. Complications were graded and reported using the Clavien-Dindo classification. Grades I and II were defined as minor and grades III and higher were defined as major complications. RESULTS: We reviewed the charts of the first 209 patients to undergo LSG. The mean body mass index was 49.2, 81% were women and the average age was 43 years. Comorbidities included hypertension (55.0%), obstructive sleep apnea (46.4%), dyslipidemia (42.1%), diabetes (37.3%), osteoarthritis (36.4%) and cardiovascular disease with previous cardiac stents (5.3%). Furthermore, 38.3% of patients reported psychiatric diagnoses, such as depression and anxiety. The overall 30-day complication rate was 15.3%. The complication rate for minor complications was 13.4% and for major complications was 1.9% (2 leaks, 1 stricture and 1 fistula). CONCLUSION: Our results support the feasibility of safely performing LSG surgery at bariatric centres completing fewer than 125 procedures annually.

CONTEXTE: Comme la province de Terre-Neuve-et-Labrador (T.-N.-L.) a le taux d'obésité le plus élevé au Canada, un programme de chirurgie bariatrique a été mis en place au Centre des sciences de la santé de T.-N.-L. La présente étude rétrospective a étudié les taux de complications dans les 30 premiers jours chez plus de 200 patients consécutifs ayant subi une gastrectomie longitudinale laparoscopique (GLL) entre mai 2011 et février 2014. MÉTHODES: Après avoir effectué une analyse des dossiers et recueilli des données sur les complications postopératoires survenues dans les 30 jours, nous avons évalué et consigné les complications à l'aide de la classification de Clavien­Dindo. Les grades I et II étaient des complications mineures et les grades III et plus, des complications majeures. RÉSULTANTS: Nous avons analysé les dossiers des 209 premiers patients à avoir subi une GLL. L'indice de masse corporelle moyen était de 49,2, 81 % des patients étaient des femmes et l'âge moyen était de 43 ans. Les comorbidités comprenaient l'hypertension (55,0 %), l'apnée obstructive du sommeil (46,4 %), la dyslipidémie (42,1 %), le diabète (37,3 %), l'arthrose (36,4 %) et les maladies cardiovasculaires avec des antécédents d'endoprothèses cardiaques (5,3 %). De plus, 38,3 % des patients ont mentionné un diagnostic psychiatrique, comme la dépression ou l'anxiété. Le taux global de complications dans les 30 jours était de 15,3 %. Le taux de complications mineures était de 13,4 % et celui de complications majeures, de 1,9 % (2 fuites, 1 striction et 1 fistule). CONCLUSION: Nos résultats viennent confirmer qu'il est possible d'effectuer des GLL de façon sécuritaire dans les centres bariatriques qui pratiquent moins de 125 interventions par année.

Does the hands-on, technical training of residents in colonoscopy affect quality outcomes?

INTRODUCTION: The training of residents in colonoscopy has become an important topic as more attention is being paid to quality outcomes. PURPOSE: To determine whether colonoscopy quality outcomes are adversely affected by allowing residents to perform colonoscopies under supervision. METHODS: This retrospective cohort study was performed on all adults who underwent colonoscopy in the city of St. John's, NL, from January to June 2012 by an endoscopist who trains residents. Subjects were identified through records from the health authority. Data were extracted from the electronic medical record, including the endoscopy procedure report, the nursing record of the endoscopy, and the pathology report. Data were recorded on a standardized data sheet and entered into SPSS version 19.0 for analysis. A Chi-squared test was used for categorical data and a t test was used for continuous data. RESULTS: A total of 867 cases involving seven endoscopists and three trainees were studied. The colonoscopy was performed by an endoscopist in 673 cases and performed by a trainee in 194 cases. Mean age [59.3 (SD 12.44) years] and gender (51.7% female) were similar between groups. There was no difference in cecal intubation rate (90.6 vs. 89.2%, p = 0.544) between endoscopists and trainees. There was a difference in polyp detection (23.3 vs. 33.5%, p = 0.004) and adenoma detection (12.8 vs. 22.7%, p = 0.034) favoring the trainees. There was no difference in the average dose of Fentanyl given (98.4 vs. 94.9 mg, p = 0.066), but there was less use of Versed favoring the trainee group (3.59 vs. 3.31 mg, p = 0.002). There was no difference in the endoscopy nurses' perception of patient discomfort between groups (28.7 vs. 26.7%, p = 0.632). CONCLUSION: The presence of a trainee does not appear to adversely affect quality outcomes in colonoscopy. When the polyp and adenoma detection rates of endoscopists are low, the addition of a trainee may improve these detection rates.

Rapid Reduction in Use of Antidiabetic Medication after Laparoscopic Sleeve Gastrectomy: The Newfoundland and Labrador Bariatric Surgery Cohort (BaSCo) Study.

BACKGROUND: Patients who have undergone bariatric surgery generally need fewer medications as they experience improvement in, or even resolution of, various medical conditions, including type 2 diabetes mellitus, hypertension, and dyslipidemia. Published data on changes in medication use after laparoscopic sleeve gastrectomy, a type of bariatric surgery that is growing in popularity, are limited. OBJECTIVE: To determine whether patients took fewer medications for management of type 2 diabetes, hypertension, and dyslipidemia after laparoscopic sleeve gastrectomy, relative to preprocedure medications. METHODS: In this prospective, single-centre cohort study, a nurse practitioner used standard medication reconciliation and study data-extraction forms to interview adult patients who had undergone laparoscopic sleeve gastrectomy and determine their medication use and pertinent demographic data. The data were analyzed using generalized estimating equations and standard statistical software. Outcome measures included changes in the use of antidiabetic, antihypertensive, and antilipemic medications at 1, 3, and 6 months after the surgery. RESULTS: A total of 65 patients who underwent laparoscopic sleeve gastrectomy between May 2011 and January 2014 met the study inclusion criteria. Before surgery, the 30 patients with type 2 diabetes were taking an average of 1.9 antidiabetic medications. One month after the procedure, 15 (50%) had discontinued all antidiabetic medications, with a further decline at 3 and 6 months (p < 0.001 at each time point). Among the patients who were taking antihypertensives (n = 48) and antilipemics (n = 33) before surgery, the decline in use occurred at a more modest rate, with 6 (12%) and 2 (6%), respectively, discontinuing these medication classes within 1 month, and 12 (25%) (p = 0.001) and 8 (24%) (p = 0.015) having discontinued by 6 months. CONCLUSIONS: These findings suggest that patients with a history of type 2 diabetes mellitus, hypertension, and/or dyslipidemia who undergo laparoscopic sleeve gastrectomy are less likely to require disease-specific medications shortly after surgery.

CONTEXTE: Les patients ayant subi une chirurgie bariatrique ont généralement besoin de moins en moins de médicaments au fur et à mesure qu'ils voient leurs différentes affections, notamment le diabète sucré de type 2, l'hypertension et la dyslipidémie, s'estomper ou même se résorber. Or, il existe peu d'études publiées sur les changements apportés à la pharmacothérapie des patients ayant subi une gastrectomie longitudinale laparoscopique, une chirurgie bariatrique de plus en plus utilisée. OBJECTIF: Déterminer si les patients prennent moins de médicaments pour le traitement du diabète de type 2, de l'hypertension et de la dyslipidémie après avoir subi une gastrectomie longitudinale laparoscopique comparativement à leur situation avant l'opération. MÉTHODES: Dans cette étude de cohorte prospective menée dans un seul centre, un membre du personnel infirmier praticien a utilisé des formulaires standards de bilan comparatif des médicaments et d'extraction de données d'étude afin d'interroger des patients adultes ayant subi une gastrectomie longitudinale laparoscopique, et ce, dans le but de connaître leur consommation de médicaments ainsi que de recueillir des données démographiques pertinentes. Les données ont été analysées à l'aide d'équations d'estimation généralisées et d'un logiciel statistique courant. Les critères de jugement incluaient l'adaptation du traitement antidiabétique, antihypertenseur et hypolipémiant, un mois, trois mois et six mois après la chirurgie. RÉSULTATS: Au total, 65 patients ayant subi l'intervention chirurgicale entre mai 2011 et janvier 2014 ont été admis dans l'étude. Avant l'opération, les 30 patients atteints du diabète de type 2 prenaient en moyenne 1,9 antidiabétique. Un mois après la chirurgie, 15 (50 %) d'entre eux ont cessé de prendre des antidiabétiques, un chiffre qui a augmenté après le troisième et le sixième mois (p < 0,001 à chaque point dans le temps). Parmi les patients qui prenaient des antihypertenseurs (n = 48) et des hypolipémiants (n = 33) avant l'intervention chirurgicale, un moins grand nombre a cessé de prendre ces médicaments. Seulement 6 (12 %) patients ont cessé les antihypertenseurs et 2 (6 %) patients ont cessé les hypolipémiants après un mois, puis 12 (25 %) (p = 0,001) et 8 (24 %) (p = 0,015) respectivement après six mois. CONCLUSIONS: Ces résultats laissent croire que les patients atteints du diabète sucré de type 2, d'hypertension ou de dyslipidémie qui subissent une gastrectomie longitudinale laparoscopique courent la chance de ne plus avoir besoin de médicaments pour traiter ces maladies, et ce, peu de temps après la chirurgie.

Use of human patient simulation and validation of the Team Situation Awareness Global Assessment Technique (TSAGAT): a multidisciplinary team assessment tool in trauma education.

OBJECTIVE: Situation awareness (SA) is a vital construct for decision making in intense, dynamic environments such as trauma resuscitation. Human patient simulation (HPS) allows for a safe environment where individuals can develop these skills. Trauma resuscitation is performed by multidisciplinary teams that are traditionally difficult to globally assess. Our objective was to create and validate a novel tool to measure SA in multidisciplinary trauma teams using a HPS--the Team Situation Awareness Global Assessment Technique (TSAGAT). SETTING: Memorial University Simulation Centre. DESIGN/PARTICIPANTS: Using HPS, 4 trauma teams completed 2 separate trauma scenarios. Student, junior resident, senior resident, and attending staff teams each had 3 members (trauma team leader, nurse, and airway manager). Individual SAGATs were developed by experts in each respective field and contained shared and complimentary knowledge questions. Teams were assessed with SAGAT in real time and with traditional checklists using video review. TSAGAT was calculated as the sum of individual SAGAT scores and was compared with the traditional checklist scores. RESULTS: Shared, complimentary, and TSAGAT scores improved with increasing team experience. Differences between teams for TSAGAT and complimentary knowledge were statistically significant (p < 0.05). Mean checklist differences between teams also reached statistical significance (p < 0.05). TSAGAT scores correlated strongly with traditional checklist scores (Pearson correlation r = 0.996). Interrater reliability for the checklist tool was high (Pearson correlation r = 0.937). CONCLUSION: TSAGAT is the first valid and reliable assessment tool incorporating SA and HPS for multidisciplinary team performance in trauma resuscitation. TSAGAT could compliment or improve on current assessment methods and curricula in trauma and critical care and provides a template for team assessment in other areas of surgical education.

Access to trauma systems in Canada.

BACKGROUND: Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care. METHODS: A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care. RESULTS: In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions. DISCUSSION: Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Trauma education and assessment.

Trauma education has evolved over the past 30 years from an unstructured preceptorship to standardised courses offered worldwide. The Advanced Trauma Life Support (ATLS) course has formed the backbone of trauma management philosophy and has spawned a series of courses aimed at specific patient populations and health care groups. Trauma education and assessment for advanced trainees has taken the form of formal clinical fellowships. In addition to clinical experience, a number of tools have been validated in aiding trauma education including use of videotape review and simulation technology. Future emphasis on development and validation of teaching and assessment techniques could improve trauma education and secondarily impact trauma outcomes worldwide.

Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment.

BACKGROUND: Situation awareness (SA) is defined as the perception of elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future. This construct is vital to decision making in intense, dynamic environments. It has been used in aviation as it relates to pilot performance, but has not been applied to medical education. The most widely used objective tool for measuring trainee SA is the Situation Awareness Global Assessment Technique (SAGAT). The purpose of this study was to design and validate SAGAT for assessment of practical trauma skills, and to compare SAGAT results to traditional checklist style scoring. METHODS: Using the Human Patient Simulator, we designed SAGAT for practical trauma skills assessment based on Advanced Trauma Life Support objectives. Sixteen subjects (four staff surgeons, four senior residents, four junior residents, and four medical students) participated in three scenarios each. They were assessed using SAGAT and traditional checklist assessment. A questionnaire was used to assess possible confounding factors in attaining SA and overall trainee satisfaction. RESULTS: SAGAT was found to show significant difference (analysis of variance; p < 0.001) in scores based on level of training lending statistical support to construct validity. SAGAT was likewise found to display reliability (Cronbach's alpha 0.767), and significant scoring correlation with traditional checklist performance measures (Pearson's coefficient 0.806). The questionnaire revealed no confounding factors and universal satisfaction with the human patient simulator and SAGAT. CONCLUSIONS: SAGAT is a valid, reliable assessment tool for trauma trainees in the dynamic clinical environment created by human patient simulation. Information provided by SAGAT could provide specific feedback, direct individualized teaching, and support curriculum change. Introduction of SAGAT could improve the current assessment model for practical trauma education.