01.18 Piloting a Low-Cost, Low-Fidelity Nontechnical Skills Training Curriculum in Cardiothoracic Surgery

I. K. Eng1, J. S. Kim1, I. Park2, Y. Kim2, K. Chen3, N. J. Jackson3, M. H. Kwon2  1David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Division Of Cardiothoracic Surgery, Department Of Surgery, Los Angeles, CA, USA 3David Geffen School Of Medicine, University Of California At Los Angeles, Department Of Medicine Statistics Core, Los Angeles, CA, USA


Nontechnical surgical skills are paramount to improving patient safety, as failures in teamwork, leadership, and communication underlie nearly 60% of perioperative complications. The Nontechnical Skills for Surgeons (NOTSS) taxonomy, comprised of situation awareness, decision making, leadership, communication and teamwork, has been validated as a reliable framework for teaching and assessment, but is often costly to implement. Recognizing that the resources to simulate high-fidelity clinical scenarios may not be accessible to all, we sought to pilot a low-cost, low-fidelity NOTSS curriculum within a cardiothoracic surgery training program. 


Four cardiothoracic surgery fellows (PGY6-7) participated in two days of low-fidelity NOTSS simulations separated by three months. On each day, the fellows underwent two distinct scenarios that assessed their cognitive (situation awareness, decision making) and social (communication and teamwork, leadership) skills. Performance in the four NOTSS categories was evaluated by NOTSS-trained course directors. The fellows also completed pre- and post-simulation self-evaluations to assess their confidence levels with respect to the four NOTSS categories. Both measures were scored on a 4-point Likert scale. Between the two days of simulation, fellows attended a formal lecture on the NOTSS taxonomy and were provided self-study materials. NOTSS performance was reported as median with interquartile range and compared across days using a paired t-test. Percent change in fellow confidence score within each day was reported as a mean and compared across days using a mixed-effects linear regression model.


In the low-fidelity NOTSS curriculum, the fellows demonstrated improvement in overall NOTSS scores between the two days (2.62[2.52-2.69] vs 3.17[3.06-3.19], p<0.01). Within the cognitive and social skills scenarios, there was a significant improvement in leadership score (2.33[2.17-2.42] vs 3.00[3.00-3.08], p=0.03), which was not observed in situation awareness, decision making, and communication and teamwork. With regards to fellows’ self-confidence between pre- and post-simulation on each day, there was an increase in confidence levels on day 2 compared to day 1 in the overall NOTSS category (-8.03% vs +5.65%, p=0.07) as well as when divided into cognitive (-13.67% vs +8.22%, p = 0.09) and social (-4.46% vs +3.93%, p=0.49) skills, though it was not statistically significant. 


We have developed a NOTSS curriculum in cardiothoracic surgery with minimal costs and technology requirements that can be formally integrated into surgical training. While improvement in assessment scores was limited to leadership, fellows showed greater confidence across both cognitive and social skills following the curriculum. We thus present a novel, low-fidelity NOTSS framework to teach, assess, and refine trainees’ nontechnical surgical skills regardless of a program’s available resources.