Boot cAMP: educational outcomes after 4 successive years of preparatory simulation-based training at onset of internship.

PURPOSE: Preparatory training for new trainees beginning residency has been used by a variety of programs across the country. To improve the clinical orientation process for our new postgraduate year (PGY)-1 residents, we developed an intensive preparatory training curriculum inclusive of cognitive and procedural skills, training activities considered essential for early PGY-1 clinical management. We define our surgical PGY-1 Boot Camp as preparatory simulation-based training implemented at the onset of internship for introduction of skills necessary for basic surgical patient problem assessment and management. This orientation process includes exposure to simulated patient care encounters and technical skills training essential to new resident education. We report educational results of 4 successive years of Boot Camp training. Results were analyzed to determine if performance evidenced at onset of training was predictive of later educational outcomes. METHODS: Learners were PGY-1 residents, in both categorical and preliminary positions, at our medium-sized surgical residency program. Over a 4-year period, from July 2007 to July 2010, all 30 PGY-1 residents starting surgical residency at our institution underwent specific preparatory didactic and skills training over a 9-week period. This consisted of mandatory weekly 1-hour and 3-hour sessions in the Simulation Center, representing a 4-fold increase in time in simulation laboratory training compared with the remainder of the year. Training occurred in 8 procedural skills areas (instrument use, knot-tying, suturing, laparoscopic skills, airway management, cardiopulmonary resuscitation, central venous catheter, and chest tube insertion) and in simulated patient care (shock, surgical emergencies, and respiratory, cardiac, and trauma management) using a variety of high- and low-tech simulation platforms. Faculty and senior residents served as instructors. All educational activities were structured to include preparatory materials, pretraining briefing sessions, and immediate in-training or post-training review and debriefing. Baseline cognitive skills were assessed with written tests on basic patient management. Post-Boot Camp tests similarly evaluated cognitive skills. Technical skills were assessed using a variety of task-specific instruments, and expressed as a mean score for all activities for each resident. All measurements were expressed as percent (%) best possible score. Cognitive and technical performance in Boot Camp was compared with subsequent clinical and core curriculum evaluations including weekly quiz scores, annual American Board of Surgery In-Training Examination (ABSITE) scores, program in-training evaluations (New Innovations, Uniontown, Ohio), and operative assessment instrument scores (OP-Rate, Baystate Medical Center, Springfield, Massachusetts) for the remainder of the PGY-1 year. RESULTS: Performance data were available for 30 PGY-1 residents over 4 years. Baseline cognitive skills were lower for the first year of Boot Camp as compared with subsequent years (71 ± 13, 83 ± 9, 84 ± 11, and 86 ± 6, respectively; p = 0.028, analysis of variance; ANOVA). Performance improved between pretests and final testing (81 ± 11 vs 89 ± 7; p < 0.001 paired t test). There was statistically significant correlation between Boot Camp final cognitive test results and American Board of Surgery In-Training Examination scores (p = 0.01; n = 22), but not quite significant for weekly curriculum quiz scores (p = 0.055; n = 22) and New Innovations cognitive assessments (p = 0.09; n = 25). Statistically significant correlation was also noted between Boot Camp mean overall skills and New Innovations technical skills assessments (p = 0.002; n = 25) and OP-Rate assessments (p = 0.01; n = 12). CONCLUSIONS: Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents correlate with subjective and objective clinical performance evaluations. This concurrent correlation with multiple traditional evaluation methods used to express competency in our residency program supports the use of Boot Camp performance measures as needs assessment tools as well as adjuncts to cumulative resident evaluation data.

Geographic distribution of community-acquired methicillin-resistant Staphylococcus aureus soft tissue infections.

PURPOSE: The goal of this study is to look at the geographic growth patterns of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections in our local region and to determine if specific geographic areas are at increased risk. METHODS: After Institution Review Board approval (132603-3), a retrospective chart review was conducted of 614 patients who underwent incision and drainage of an abscess by a single pediatric surgical practice from January 2004 to December 2008. In addition, previously published data from 195 patients who underwent incision and drainage of an abscess from January 2000 to December 2003 were reviewed. RESULTS: The most commonly cultured organism found in the pediatric population undergoing incision and drainage was S aureus (n = 388), of which 258 (66%) were methicillin resistant. This is a 21% increase from the rate of MRSA cultures identified from 2000 to 2003. Geographic information system space-time analysis showed that a cluster of 14 MRSA cases was located within a 1.44-km radius between 2000 and 2003, and 5 separate clusters of more than 20 MRSA infection cases each were identified in 3 separate cities over the 8-year time span using geographic information system spatial analysis (P value = .001). CONCLUSION: Methicillin-resistant S aureus has now become the most prevalent organism isolated from cultures of community-acquired abscesses requiring incision and drainage in the pediatric population in our local region. Significant clustering of MRSA infections has appeared in several different cities within our geographic region.

Geography and travel distance impact emergency department visits.

BACKGROUND: Little has been written about the geographic basis of emergency department (ED) visits. OBJECTIVE: The objective of this study is to describe the impact of geography on ED visits. METHODS: A retrospective analysis was conducted of ED visits during a 1-year period at a single institution using spatial interaction analysis that models the pattern of flow between a series of origins (census block groups) and a destination (ED). Patients were assigned to census block groups based upon their verified home address. The study hospital is the only Level I trauma, pediatric, and tertiary referral center in the area. There are 11 other hospitals with EDs within a 40-mile radius. Each patient visit within this radius, including repeat visits, was included. Patients with an invalid home address, a post office box address, or those who lived outside a 40-mile radius were excluded. ED visits per 100 population were calculated for each census block group. RESULTS: There were 98,584 (95%) visits by 63,524 patients that met study inclusion criteria. Visit rates decreased with increasing distance from the ED (p < 0.0001). Nineteen percent of patients lived within 2 miles, 48% within 4 miles, and 92% within 12 miles of the ED. The Connecticut border, 7 miles south of the ED (p < 0.0001), the Connecticut River, 1 mile west of the ED (p < 0.0001), and the presence of a competing ED within 1 mile (p < 0.0001) negatively impacted block group ED visit rates. Travel distance was related to the percentage of visits that were high acuity (p < 0.0001), daytime (p < 0.01), or resulted in admission (p < 0.0001). CONCLUSIONS: Geography and travel distance significantly impact ED visits.

Implementation of full patient simulation training in surgical residency.

PURPOSE: Simulated patient care has gained acceptance as a medical education tool but is underused in surgical training. To improve resident clinical management in critical situations relevant to the surgical patient, high-fidelity full patient simulation training was instituted at Baystate Medical Center in 2005 and developed during successive years. We define surgical patient simulation as clinical management performed in a high fidelity environment using a manikin simulator. This technique is intended to be specifically modeled experiential learning related to the knowledge, skills, and behaviors that are fundamental to patient care. We report 3 academic years' use of a patient simulation curriculum. METHODS: Learners were PGY 1-3 residents; 26 simulated patient care experiences were developed based on (1) designation as a critical management problem that would otherwise be difficult to practice, (2) ability to represent the specific problem in simulation, (3) relevance to the American Board of Surgery (ABS) certifying examination, and/or (4) relevance to institutional quality or morbidity and mortality reports. Although training started in 2005, data are drawn from the period of systematic and mandatory training spanning from July 2006 to June 2009. Training occurred during 1-hour sessions using a computer-driven manikin simulator (METI, Sarasota, Florida). Educational content was provided either before or during presimulation briefing sessions. Scenario areas included shock states, trauma and critical care case management, preoperative processes, and postoperative conditions and complications. All sessions were followed by facilitated debriefing. Likert scale-based multi-item assessments of core competency in medical knowledge, patient care, diagnosis, management, communication, and professionalism were used to generate a performance score for each resident for each simulation (percentage of best possible score). Performance was compared across PGYs by repeated-measures analysis of variance and Wilcoxon rank sum tests. RESULTS: Residents participated in 4.5 ± 1.4 sessions per academic year. Compliance with scheduled training was 88%, 90%, and 99% over successive years. Performance data were available for 39 PGY1, 2, and 3 residents. Ten individual residents could be followed between PGY1 and PGY2. For these individuals, improvement in mean performance was detected for the PGY2 (81% ± 5% vs 86% ± 4%; p < 0.01). Performance improvement was also detected for 4 individual residents who could be followed during all 3 years (82% ± 4%, 86% ± 2%, and 91% ± 1%, respectively, p < 0.005). Internal consistency for multi-item assessments was high (Cronbach's alpha = 0.80). Of note, 8 of 39 residents had performance scores >2 standard deviations below mean for the PGY level and 5 of these had deficiencies in clinical performance noted by other evaluation methods. CONCLUSIONS: Patient simulation training was implemented successfully with good compliance in this medium-sized surgical residency training program, but clear challenges were encountered with issues related to the number and range of experiences available per resident, competition with other educational activities, and fidelity and realism. Initial experience suggests that the associated assessment methods can detect predictable improvements in patient management skills across successive residency years, as well as potentially deficient management. Additional work is required to determine the educational effect of this training on resident clinical competency.

A new web-based operative skills assessment tool effectively tracks progression in surgical resident performance.

PURPOSE: The study aim was to demonstrate that a new database tool for assessment of surgical resident operative skills discerns predictable progression in those skills over successive residency years for specific index case types. METHODS: A Web-based interactive database (OpRate) was used to assess selected aspects of resident operative performance as determined by supervising attending surgeons in a medium-sized residency (5-6 residents per postgraduate year [PGY]). This assessment consisted of (1) 3 questions pertaining to patient information, technical, and disease-specific preparedness; (2) 4 laparoscopic technical skills questions pertaining to tissue handling, dexterity, planning, and ability to function independently; and (3) similar open technical skills questions, with the addition of 2 questions defining knot tying ability. Two years of assessment data were examined for cholecystectomy (CH), appendectomy (AP), colon resection (CR), ventral hernia repair (VH), and inguinal hernia repair (IH). Mean scores for total, technical, and preparedness responses, as well as each response area were compared for successive training years for each case type. Mean performance data between postgraduate years were compared by ANOVA, and interitem reliability was assessed by Cronbach's alpha determinations. RESULTS: OpRate data for 579 cases (142 CH, 67 AP, 73 CR, 202 IH, and 95 VH) were examined. Significant incremental increases in open and laparoscopic technical skills scores by training year were observed for all case types (ANOVA, p < 0.0001). Individual technical skills as well as technical and disease-specific preparedness response areas also demonstrated significant improvement by successive training year. Cronbach's alpha determinations were 0.80-0.94 for the preparedness test items and the skills performance scores for all assessed procedures. CONCLUSIONS: Our early results show that the OpRate assessment tool is effective in identifying expected changes in operative performance across successive training years, with a satisfactory level of internal consistency for the test items. As such, the use of this database tool may offer the opportunity to (1) define performance benchmarks for specific levels of training and (2) identify areas where focused training may be required for specific residents.

Using GIS for spatial analysis of rectal lesions in the human body.

BACKGROUND: Geographic Information Systems (GIS) have been used in a wide variety of applications to integrate data and explore the spatial relationship of geographic features. Traditionally this has referred to features on the surface of the earth. However, it is possible to apply GIS in medicine, at the scale of the human body, to visualize and analyze anatomic and clinical features. In the present study we used GIS to examine the findings of transanal endoscopic microsurgery (TEM), a minimally-invasive procedure to locate and remove both benign and cancerous lesions of the rectum. Our purpose was to determine whether anatomic features of the human rectum and clinical findings at the time of surgery could be rendered in a GIS and spatially analyzed for their relationship to clinical outcomes. RESULTS: Maps of rectal topology were developed in two and three dimensions. These maps highlight anatomic features of the rectum and the location of lesions found on TEM. Spatial analysis demonstrated a significant relationship between anatomic location of the lesion and procedural failure. CONCLUSION: This study demonstrates the feasibility of rendering anatomical locations and clinical events in a GIS and its value in clinical research. This allows the visualization and spatial analysis of clinical and pathologic features, increasing our awareness of the relationship between anatomic features and clinical outcomes as well as enhancing our understanding and management of this disease process.

Mapping the rectum: spatial analysis of transanal endoscopic microsurgical outcomes using GIS technology.

Transanal endoscopic microsurgery (TEM) is a technically challenging procedure hindered by rectal anatomic constraints. To study the relationship of lesion position with performance of TEM, a novel approach of spatial analysis using Geographic Information Systems (GIS) was developed. A retrospective review was conducted on 144 consecutive TEMs, analyzing clinical, pathologic, and positional characteristics. Two- and three-dimensional maps of rectal topology were developed. GIS was used for spatial analysis, accounting for regional position and clustering of lesions. Lesions were located at a mean distance of 9.3 +/- 4.9 (SD) cm from the dentate line, with an average size of 3.1 +/- 1.4 cm. Proximal regions were associated with prolonged operative time. Regions between the rectosigmoid junction and the peritoneal reflection were associated with peritoneal breach. In spatial regression analysis, regional characteristics that were significantly associated with operative time included distance, presence of cancers, and positive margins; peritoneal breach was significantly associated with lesion size and location; conversions were associated with distance (P < 0.05). Specific knowledge of lesion size and location in the context of anatomic relationships is important for optimizing operative intervention. GIS provides a valuable tool in organizing spatial information and can be extended into clinical research topics involving the distinction of anatomic relationships.

Geographic information system localization of community-acquired MRSA soft tissue abscesses.

BACKGROUND: Soft tissue infections with methicillin-resistant Staphylococcus aureus (MRSA) pose an ever-increasing risk to children in the community. Although historically these infections were limited to children with prolonged hospitalization, the authors have seen an increase in community-acquired infections in children without identifiable risk factors. The goal of this study is to determine the incidence of truly community-acquired MRSA soft tissue infections in our community and geographically map regions of increased risk. METHODS: After obtaining the institutional review board's approval, a retrospective chart review was conducted on 195 patients records who underwent an incision and drainage of soft tissue infections from January 1, 2000, to December 31, 2003. Thirteen patients were excluded from the study because no cultures were taken at the time of incision and drainage. RESULTS: The most common organism isolated from wound culture was S aureus , 40% (73/182), of which 45% (33/73) were MRSA. Eighty-one percent (27/33) of MRSA infections were in Springfield, 1 of 18 towns represented in the patient population. Geographic information system analysis identified a significant MRSA cluster 1.96 km in diameter within the city of Springfield. CONCLUSIONS: Geography proved to be a significant risk factor for presenting with MRSA infection. Geographic maps of antibiotic resistance can be used to guide physician antibiotic selection before culture results are available. This has significant implications for the health care provider in proper antibiotic selection within the community.

Profile of chest trauma in a level I trauma center.

BACKGROUND: Chest injuries are seen with increasing frequency in urban hospitals. The profile of chest injuries depends on the size of the hospital and the level of trauma center. The data regarding the true incidence of chest trauma are scant. METHODS: One thousand three hundred fifty-nine consecutive patients seen at a Level I trauma center were analyzed. The nature of injury, methods of treatment, and morbidity and mortality were recorded in a prospective manner and analyzed retrospectively. Multiple logistic regression analysis was used to determine the independent predictors of mortality after chest trauma. RESULTS: The overall mortality was 9.41%. Low Glasgow Coma Scale score, older age, presence of penetrating chest injury, long bone fractures, fracture of more than five ribs, and liver and spleen injuries were independent predictors of death after chest trauma. A model was created for predicting the mortality based on various factors. CONCLUSION: Most chest injuries can be treated with simple observation. Only 18.32% of patients required tube thoracostomy and 2.6% needed thoracotomy. Low Glasgow Coma Scale score and advanced age are the most significant independent predictors of mortality.

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction.

BACKGROUND: The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate. METHODS: After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77. RESULTS: Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet. CONCLUSIONS: U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.