The trend toward minimally invasive complex abdominal wall reconstruction: is it worth it?

BACKGROUND: Open abdominal wall reconstruction (AWR) was previously one of the only methods available to treat complex ventral hernias. We set out to identify the impact of laparoscopy and robotics on our AWR program by performing an economic analysis before and after the institution of minimally invasive AWR. METHODS: We retrospectively reviewed inpatient hospital costs and economic factors for a consecutive series of 104 AWR cases that utilized separation of components technique (57 open, 38 laparoscopic, 9 robotic). Patients were placed into two groups by date of procedure. Group 1 (Pre MIS) was July 2012-June 2015 which included 52 open cases. Group 2 (Post MIS) was July 2015-August 2016 which included 52 cases (5 open, 38 laparoscopic, 9 robotic). RESULTS: A total of 104 patients (52 G1 vs. 52 G2) with mean age (54.2 vs. 54.1 years, p = 0.960), BMI (34.7 vs. 32.1 kg/m2, p = 0.059), and ASA score (2.5 vs. 2.3, p = 0.232) were included in this review. Total length of stay (LOS) was significantly shorter for patients in the Post MIS group (5.3 vs. 1.4 days, p < 0.001). Although operating room (OR) supply costs were $1705 higher for the Post MIS group (p = 0.149), total hospital costs were $8628 less when compared to the Pre MIS group (p < 0.001). Multiple linear regressions identified increased BMI (p = 0.021), longer OR times (p = 0.003), and LOS (p < 0.001) as predictors of higher total costs. Factors that were predictive of longer LOS included older patients (p = 0.003) and patients with larger defect areas (p = 0.004). MIS was predictive of shorter hospital stays (p < 0.001). CONCLUSIONS: Despite an increase in operating room supply costs, transition to performing MIS AWR in cases that were previously done through an open approach decreased LOS and translated into significant overall total cost savings.

Standardized Patient Encounters: Periodic Versus Postencounter Evaluation of Nontechnical Clinical Performance.

INTRODUCTION: Standardized patients are a beneficial component of modern healthcare education and training, but few studies have explored cognitive factors potentially impacting clinical skills assessment during standardized patient encounters. This study examined the impact of a periodic (vs. traditional postencounter) evaluation approach and the appearance of critical verbal and nonverbal behaviors throughout a standardized patient encounter on scoring accuracy in a video-based scenario. METHODS: Forty-nine standardized patients scored either periodically or at only 1 point in time (postencounter) a healthcare provider's verbal and nonverbal clinical performance during a videotaped standardized patient encounter. The healthcare provider portrayed in this study was actually a standardized patient delivering carefully scripted verbal and nonverbal behaviors in their portrayal of an actual physician. The encounter itself was subdivided into 3 distinct segments for the purpose of supporting periodic evaluation, with the expectation that both verbal and nonverbal cues occurring in the middle segment would be more challenging to accurately report for participants in the postscenario evaluation group as a result of working memory decay. RESULTS: Periodic evaluators correctly identified a significantly greater number of critical verbal cues midscenario than postencounter evaluators (P < 0.01) and correctly identified a significantly greater number of critical nonverbal cues than their postscenario counterparts across all 3 scenario segments (P < 0.001). Further, postscenario evaluations exhibited a performance decrement in terms of midscenario correct identifications that periodic evaluators did not (P < 0.01). Also, periodic evaluators exhibited fewer verbal cue false-positives during the first segment of the scenario than postscenario evaluators (P < 0.001), but this effect did not extend to other segments regardless of the cue type (ie, verbal or nonverbal). DISCUSSION: Pausing lengthier standardized patient encounters periodically to allow for more frequent scoring may result in better reporting accuracy for certain clinical behavioral cues. This could enable educators to provide more specific formative feedback to individual learners at the session's conclusion. The most effective encounter design will ultimately depend on the specific goals and training objectives of the exercise itself.

Theoretically-driven infrastructure for supporting health care teams training at a military treatment facility.

Designated a Department of Defense Team Resource Center (TRC) in 2008, Naval Medical Center Portsmouth (NMCP) currently hosts three tri-service health care teams training courses annually. Each consists of didactic learning coupled with simulation-based training exercises to provide an interactive educational experience for health care professionals. Simulated cases are developed to reinforce specific teamwork skills and behaviors, and to incorporate a variety of technologies including standardized patients, manikins, and virtual reality. The course is also the foundation of a research program designed to explore applications of modeling and simulation for enhanced team training in health care. The TRC has adopted two theoretical frameworks for evaluating training efficacy and outcomes, and has used these frameworks to guide a systematic reconfiguration of the infrastructure supporting health care teams training at NMCP.