94.14 Is Video Observation as Effective as Live Observation for Improving Operating Room Teamwork?

Posted on January 26, 2017

A. H. Bui1, S. Guerrier1, D. L. Feldman1,2, P. Kischak2, S. Mudiraj2, D. Somerville2, M. Shebeen1, C. Girdusky1, I. Leitman1  2Hospitals Insurance Company,New York, NY, USA 1Mount Sinai School Of Medicine,Surgery,New York, NY, USA

Introduction: Teamwork in the operating room is necessary for avoiding preventable errors that can lead to patient injury and even death. Direct and indirect observation methods in the OR such as the use of live observers or video cameras allow for the evaluation of surgical performance and compliance with best-practice guidelines. They also allow for provision of either immediate or delayed feedback to the surgical team. However, little is known about how these methods compare to each other in improving OR teamwork. This study examines the relative effectiveness of video and live observation.

Methods:  As part of a patient safety quality improvement initiative, video and audio cameras were installed in 2014 to record all activities within the ORs of an 875 bed urban hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized, validated tool was used to evaluate time-outs (briefs) and sign-out (debriefs) by the OR team, serving as a proxy measure of compliance with TeamSTEPPS skills. Feedback was given to OR teams either in real-time during live observation or in writing following review of the video recording. Fisher’s exact tests were used to compare compliance with these skills under live vs. video observation.

Results: A total of 1,410 time-outs were evaluated: 325 (23%) through live observation, 1,085 (77%) through video. A total of 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs. 44%, p<0.001), anticipation of complex procedural events (61% vs. 45%, p<0.001), and resource monitoring (58% vs. 42%, p<0.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs. 60%, p<0.001) establishment of a leader (70% vs. 51%, p<0.001), discussion of postoperative plan (77% vs. 48%, p<0.001), what went well and what needs improvement (49% vs. 33%, p<0.001), engagement of all team members (64% vs. 41%, p<0.001), and check back (61% vs. 46%, p<0.001) compared to video. More barriers to compliance were noted in video compared to live observation for briefs (p<0.001) and debriefs (p=0.004). 

Conclusion: Video may not be as effective as live observation in promoting OR communication and teamwork. The role of live, video, and other forms of external feedback in improving OR team performance and patient outcomes needs to be further evaluated. Live observations enable immediate feedback, which may improve behavior and reduce barriers to full compliance with surgical safety practices.

94.13 Surgeons, engineers, & haptics: Designing a better robot training model for central line insertion

Posted on January 26, 2017

K. A. Mirkin1, D. Pepley3, M. Yovanoff2,4, S. Miller2,4, J. Moore3, D. C. Han1  1Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA 2The Pennsylvania State University,Department Of Industrial Engineering,State College, PA, USA 3The Pennsylvania State University,Department Of Mechanical And Nuclear Engineering,State College, PA, USA 4The Pennsylvania State University,School Of Engineering Design,State College, PA, USA

Introduction:
Surgical simulation continues to increase its value as a means to provide a safe environment to educate trainees in the performance of invasive procedures.  Advances in the incorporation of haptic feedback in the use of robotic simulators have increased the fidelity of the simulated experience.  As the technology continues to develop, the need for a greater depth of understanding often supersedes the benefit of a wider breadth of familiarity.  User-centered design allows a practical perspective to be coupled with the power of expertise in this ever-growing depth of technology.  Achieving this goal can require a diverse team of collaborators.  Herein we report the development of a dynamic haptic robot training model for central venous catheterization simulation.

Methods:
An interdisciplinary team consisting of mechanical engineers with expertise in haptic robot design and industrial engineers with expertise in process design collaborated with surgeons at an academic medical center to develop a dynamic haptic robot (DHR) for training the process of central venous catheter insertion. This was a pilot trial of 13 surgical residents familiar with the central line insertion procedure but never exposed to the DHR.  Residents performed two procedures with the DHR.  The program measured 6 parameters (needle angle, aspiration percentage, number of attempts, radial distance from center of vein, penetration of back wall, successful venous access) and used them to calculate an overall grade for the performance. Univariate analysis using a student’s t-test was performed to evaluate the residents’ ability to make corrective adjustments within these 6 parameters before and after working with the DHR. 

Results:
Residents saw an overall 28% improvement after one interaction with the DHR (p=0.0393).  This significant improvement indicates users were able to constructively utilize the feedback given to improve their performance.  The average of all individual performance parameters increased between the first and second attempt.  No specific performance parameter was found to be consistently deficient among users. 

Conclusion:

Exposure to the DHR system afforded an overall improvement in central venous access technique.  The lack of any consistently deficient specific performance pattern suggests that the system and the feedback provided allowed users to significantly improve.  Further studies are needed to determine if repeated exposure to this training technique results in more substantial improvements, if this training regimen is superior to existing modalities, and if improvements using this training method in central venous catheterization will also extend to other invasive surgical procedures.

 

This research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R01HL127316.

94.12 Maturation of Effect Size During Enrollment of Prospective Randomized Trials

Posted on January 26, 2017

A. S. Poola1, T. Oyetunji2, G. W. Holcomb1, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Surgery,Kansas City, MO, USA 2Lurie Children’s Hospital-Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
 Randomized trials with a definitive study design are powered by calculating the minimum sample required to achieve statistical significance given an estimated effect size (ES). The ES is the raw difference between two treatment arms. ES quantifies the magnitude of measurable differences between cohorts and is usually reflective of the true meaning of the trial regardless of statistical significance. Under a fixed protocol, we hypothesize that the effect size may mature near its final magnitude well before the completion of enrollment. To investigate patterns of ES during enrollment, we analyzed completed randomized trials with definitive study designs. 

Methods:
Primary outcomes of 11 prospective trials were reviewed at a single institution. ES was calculated at intervals throughout each trial to determine at which point a steady clinical difference was achieved between treatment cohorts. 

Results:
Table 1 summarizes our overall findings. Both the completed trial sample size and the number of enrolled patients at which the ES stabilized, are provided. ES stabilized at a median of 64% enrollment. All patients were needed to meet the precise ES in our smallest study, indicating the need for full enrollment in smaller studies. Otherwise, 50% of our trials required between 48% and 76% of patient enrollment to meet ES. In comparing clinical outcomes, 9 of 12 found a final difference that was nearly identical to the difference that could have been determined much earlier. Categorical outcomes met stabilized ES at 51% enrollment and continuous outcomes at 68%.

Conclusion:
ES and final clinical outcomes were achieved prior to the completion of enrollment for most of our studies. This suggests that clinical differences detected by randomization may not necessarily require the robust sample size often needed to establish statistical significance. This is particularly relevant in fixed-protocol interventional trials of homogenous populations where protocol compliance is high. 
 

94.11 Social Media and Visual Abstracts to Disseminate Surgical Science

Posted on January 26, 2017

A. M. Ibrahim1, K. D. Lillemoe2, M. E. Klingensmith3, J. Dimick1  1University Of Michigan,Surgery,Ann Arbor, MI, USA 2Massachusetts General Hospital,Boston, MA, USA 3Washington University,St. Louis, MO, USA

Introduction: Surgical research is growing at an unprecedented rate making it increasingly difficult for surgeons to keep up to date. In response, many academic journals have adopted social media services, including Twitter, to disseminate their publications. It is unclear, however, what the most effective social media formats are to disseminate surgical research.

Methods: More than 1.6 million impressions were analyzed from the Twitter account of Annals of Surgery between January and August of 2016. Data was obtained and merged from three sources: Twitter Analytics, Altmetric and Symplur. We assed three different types of Tweets (Figure 1) that were introduced in a stepwise fashion over the study period beginning with (1) title alone, then (2) title with figure, and finally (3) a visual abstract. Our primary outcomes used to measure dissemination  included impressions (number of times a tweet was seen), retweets (number of times a tweet was shared) and article views (number of times a tweet led to a view on the article on publisher website.)

Results:   We found a strong correlation between the use of visual tweets and extent of dissemination. When only article titles were tweeted, the account averaged per week, 40,863 impressions, 83 retweets and 643 article views.  However, after introduction of tweets including article figures and visual abstracts, the account averaged per week 108,987 impressions (2.6 fold increase), 416 retweets (5.1 fold increase) and 1092 article views (1.7 fold increase.) Further, individual tweets with a visual abstract were able to achieve >15,000 impressions and >100 retweets within one week compared to only ~4,600 impressions and ~22 retweets for tweets including only the article title. Subset analysis of selected articles with a Visual Abstract revealed that65% of article views on the publisher website were attributed to discovery through Twitter.

Conclusions: Social Media, including Twitter, is an effective platform to disseminate surgical science. The use of visual abstracts was associated with higher levels of dissemination as measured by impressions, shares and article visits on the publishers website. All academic researchers and publishers should consider using visual design and social media to make their research more engaging and accessible.  

94.10 Does Teaching the FAST Exam to High School Students Enhance Learning Among Medical Students?

Posted on January 26, 2017

B. L. Gas1, E. Buckarma1, M. Mohan1, T. Pandian1, N. Naik1, W. Thompson1, E. Abbott1, A. Jyot1, M. Zeb1, S. Allen1, D. R. Farley1  1Mayo Clinic,General Surgery,Rochester, MN, USA

Introduction: The objective of this study was to determine if medical students’ knowledge and technical performance of a FAST (Focused Assessment with Sonography for Trauma) exam could be enhanced by teaching high school students how to perform this exam.

Methods: Twenty-three 1st  through 4th year medical students (MS) completed a pre-test comprised of two parts: (1) five question quiz (5 total points) and (2) FAST exam (25 total points) on a standardized patient. Following the pre-test, general surgical residents taught MS for 90 minutes using both lecture and hands-on simulation. The MS immediately completed a post-test (PT 1), which was identical to the pre-test. Four weeks later, 8 of the MS taught 120 high school students (HS) how to perform a FAST exam. The MS taught independently, with no oversight given. MS who did not teach HS received a video link which outlined the FAST exam diagnostic steps. Eight weeks after the pre-test, MS participants completed a second post-test (PT 2) which was identical to the pre-test. Scores between MS who taught HS and those who did not were compared.

Results: Fifteen MS completed the pre-test and both post-tests; of these, six taught HS and nine received the instructional videos. Overall, there was improvement from the pre-test to PT 1 both with the quiz (mean score improved from 2.3 to 4.9, p<.001) and FAST exam (mean score improved from 6.5 to 21.3, p<.001). However, both scores decreased from PT 1 to PT 2 (mean quiz score 4.9 to 4 and mean FAST score 21.3 to 12; p≤.001). MS who taught HS scored higher on the FAST exam technique portion of PT 2 compared to MS who received instructional videos (17.5 and 8.3, respectively; p=.01).

Conclusion: Allowing medical students to give hands-on teaching of medical information or the actual skill of a FAST exam to high school students improves MS long term retention compared with receipt of video-based instruction. Skill and knowledge decay did occur with both groups over 8 weeks of time. Hands on learning with sequential exposure remains a powerful educational format for long term retention.

 

94.09 Informed, Informed Consent

Posted on January 26, 2017

K. C. Cates1, T. Miner1  1Brown University School Of Medicine,General Surgery,Providence, RI, USA

Introduction: The conversation held between a physician and patient when obtaining informed consent is both complex and important.  In the inpatient setting, consent often obtained by a junior resident. The purpose of this study was to prepare interns to obtain informed consent.  We hypothesized that an educational session outlining elements of consent would augment an intern’s ability to consent his/her patients.

Methods:   Surgery interns were given a pre-test in which their ability to give informed consent was assessed.  They were graded based off a rubric earning one point was given for addressing each of the following: identification of self, explanation of the situation and indication for the procedure, nature of the procedure, description of the steps involved, providing expectations, explanation of risks, benefits or alternatives, asking for questions and asking for consent.  A didactic session was then held reviewing the grading rubric.  Thereafter, a post-test was taken.  The interns were retested for retention at 3 and 6 month intervals.  Those who were not present for the initial information session were also tested throughout the year, serving a control group.

Results:  Thirteen interns participated in the study; 9 were involved in the study group and 4 were controls.  Statistical significance was calculated using student’s paired t test to compare pre and post-test results and unpaired t tests to compare the intervention and control groups at 3 and 6 month intervals.  In the study group, post-test average score increased as compared to pre-test but not to a degree that was statistically significant (pre-test avg 6.6/7, post 6.9/7 p= 0.39).  The study group's performed was higher than the control group, but these findings were not statistically significant (study group 3 month avg 6.1/7 vs. control 5.5/7, p= 0.51; study group 6 month avg 6.0/7 vs. control 5.0/7 p=0.21).  The most frequent omission was discussion of risks, benefits and alternatives, addressed in 70% of test.

Discussion:  An educational session providing guidelines for obtaining informed consent yielded a trend of improved performance; these findings were not statistically significant.  We hypothesize that if this experiment were to be repeated with a larger group results might reach a level of statistical significance. This suggests a benefit in providing informed consent educational sessions at the onset of training.  Overall, all groups showed regression over time.  This may be reflect a sense of confidence that is built by repeated iterations of task and concomitant reflexive approach rather that active thinking about the task at hand.  The most frequently omitted element of consent was a core topic in informed consent; discussion of risks, benefits or alternatives.  Knowledge of this trend will ideally provide motivation to maintain attention to detail throughout the course of one’s practice in obtaining consent.

94.08 Dr. Google: The Readability and Accuracy of Patient Education Websites for Graves’ Disease Treatment

Posted on January 26, 2017

A. Purdy1, A. Idriss1, S. Ahern1, B. Van Blarigan1, J. Bulter1, D. Elfenbein1  1University Of California, Irvine,Orange, CA, USA

Introduction:

National guidelines for the treatment of Graves’ hyperthyroidism emphasize the importance of incorporating patient preferences into treatment recommendations. In order for patients to express a true preference, they must have an understanding of their options. Today, many turn to the internet as a source of information. Most patients are initially treated with anti-thyroid drugs (ATD), and then ultimately may choose between radioactive iodine ablation (RAI), or surgery for definitive treatment. Our primary objective was to compare the readability and accuracy of patient-oriented online resources for Graves’ Disease by treatment modality and website.

Methods:

A systematic internet search for treatment of Graves’ Disease was used to identify the most popular websites that discussed all 3 treatment modalities. Readability was measured by 9 standardized tests, and the median readability scores were compared among treatment modalities and websites. Accuracy was assessed by an expert panel, consisting of two endocrine surgeons and three endocrinologists. Raters were asked to score the accuracy of documents on a scale of 1-5. Finally, percentage of space on the website dedicated to each of the three treatment options was calculated.

Results: We identified 11 websites that ranked highly using every search strategy and search engine used, and included 2 lower ranking but informative websites from professional organizations. Of the 13 sites, 2 were authored by academic institutions, 2 by government agencies, 5 by non-profit, and 4 by private entities. Readability varied between sites from an 8th to a 13th grade level. The websites differed in the amount of space dedicated to each of the 3 treatment modalities, with the most space dedicated to discussing RAI (mean=41%). There was overall fair to moderate agreement among expert reviewers about the accuracy of the information presented, (Intraclass Correlation Coefficient=0.3-0.41). Accuracy as assessed by our expert panel ranged from a mean of 2.75 (out of 5) for the least accurate to 4.5 for the most accurate. The two least accurate websites overall were authored by private entities; two of the top three most accurate were academic institutions and the third is a popular collaboratively-written website.

Conclusion:

Information that patients obtain from the internet may help shape their preferences for certain treatments before they even see a health care provider. Our analysis found that for Graves’ disease treatments, the most inaccurate websites rank high using traditional internet search methods, and some highly accurate patient education websites were only found using strategies the average patient likely will not use, such as searching by professional organization name. As treatment recommendations are constantly evolving, professional organizations and academic centers must take steps to make sure patients have access to the most accurate information for treatment decisions.

94.07 Novel development of navigation surgery by augmented reality using a tablet PC

Posted on January 26, 2017

J. Yasuda1, T. Okamoto2, S. Onda1, A. Hattori3, N. Suzuki3, K. Yanaga1  1Jikei University School Of Medicine,Department Of Surgery,Tokyo, , Japan 2Jikei Daisan Hospital,Department Of Surgery,Tokyo, , Japan 3Jake University School of Medicine,Institute For High Dimensional Medical Imaging,Tokyo, , Japan

 

Introduction:

We reported the efficacy of an image-guided navigation system using augmented reality (AR-NS) technology for hepatobiliary and pancreatic surgery. We have superimposed the 3D organ model and the real organ in a display monitor using a stereoscope and were able to decipher the patient’s anatomy on the display monitor (Monitor method).

However, this navigation system had some problems such as high price of a dedicated stereoscope,?and surgeon’s eyesight away from the surgical field.

Therefore, we have developed a novel image-guided navigation system using a tablet PC which seems overspread in the world (Tablet method). This inexpensive device does not require changing eyesight away.

 

Methods:

We applied this tablet PC five patients who underwent navigation surgery for hepatobiliary and pancreatic field. Operative procedures consisted of hepatectomy in 3 and pancreatectomy in 2.

Surgical planning was contemplated using a 3D organ model, which was created from dynamic enhanced CT.

Positional measurement for registration was performed using a position sensor Optotrak® installed in the special operating room. After paired point registration, the surgical field was captured by the tablet PC with an infrared sensor, on which the 3D organ model was superimposed. This model data was sent via Wi-Fi to the tablet PC for real time navigation. The operation was performed with navigation guidance which included the localization of the tumor and blood vessels at various angles. The registration accuracy was calculated as the fiducial registration error (FRE). Furthermore, The tablet PC allowed writing characters on the screen. We employed this technique for education using the annotation function operated by a resident and a nurse by transmitting a superimposed image on a bedside monitor via Bluetooth.

Results:

The time required to build a 3D organ model was 2−3 hr per patient. Registration took only 1−2min for each procedure. Using Wi-Fi, AR-NS was possible without a time lag, and navigation surgery was successfully performed in all patients. The visibility of the superimposed models in the tablet PC was compatible with that of the monitor method [Fig.1]. This resulted in improved understanding of the operation by residents and nurses. About the registration precision, the mean FRE was 6.3 mm which did not differ from Monitor method.

Conclusion:

Novel Tablet method may make AR-NS more convenient than Monitor method in abdominal surgery.

 

 

94.06 A Cost Savings Approach to Suture Training Utilizing Self-Made Synthetic Multi-Layer Skin Models

Posted on January 26, 2017

H. Buettner2, K. Patel1, J. Yoo1,2, A. Chatterjee1,2, L. Chen1,2  1Tufts Medical Center,Department Of Surgery,Boston, MA, USA 2Tufts University School Of Medicine,Boston, MA, USA

Introduction:  Experience with basic tissue handling, suturing and wound closure is difficult to provide to medical students and junior surgical residents due to limitations with current models.  Existing synthetic skin models do not provide accurate tactile sensation and are prohibitively expensive.  Cadaver or animal tissue is also expensive, requires a laboratory, and exposes trainees to biohazards.  There is a need for a safe, cost-effective, and reusable skin model for trainees to gain experience with suturing and wound closure techniques before performing these procedures in the operating room.

Methods:  Our synthetic skin model is designed to have simulated epidermal/dermal, subcutaneous fat and muscle layers.  The template consisted of vinyl fabric affixed to plywood, which provides a flat surface with dermal texture. The template was layered with the following in sequence: medium density silicone rubber imbedded with two way stretch mesh fabric to emulate dermis and epidermis, a softer layer of low density silicone gel to emulate subcutaneous fat, and a final layer of medium density silicone rubber to emulate muscle. All materials were readily available from various suppliers. Surgical residents tested the clinical qualities of the skin models.

Results: A linear incision was made and our model was tested for appropriate resistance to needle and suture, ability to retain stitches, and durability. The residents were able to perform simple interrupted sutures, dermal and epidermal reapproximation, and everting sutures.  The model could be re-used during multiple sessions.  The cost of this model was $0.42 per square inch. Comparative models cost $1.20-$1.99 per square inch.

Conclusion: We developed a cost saving synthetic model that closely mimics properties of human tissue and can be easily prepared by trainees and lab coordinators.

 

94.05 Maximizing Resident Acceptance of Surgical Simulation: An Institutional Experience

Posted on January 26, 2017

U. P. Nag1, S. R. Sprinkle1, M. L. Cox1, M. C. Turner1, R. Sudan1  1Duke University Medical Center,General Surgery,Durham, NC, USA

Introduction:  Simulation has become a critical adjunct for surgical education in an era of duty hour restrictions alongside increasing scrutiny on patient safety, quality, and cost containment. Varying modalities, including virtual reality simulators and tissue-based models, have been developed to recreate the operative experience in a low risk environment. We aim to assess resident perceptions of simulation curricula utilizing tissue-based activities compared to dry models. 

Methods:  A survey was created using Qualtrics (Provo, UT, http://www.qualtrics.com) and distributed to the general surgery residency cohort at a single institution.  Anonymous responses were collected from January to February 2016. A mix of dry simulation models (virtual reality laparoscopic trainer, laparoscopic box trainer, vascular anastomosis model and robotic simulator) and tissue based activities (cadaver or live animal lab operations) were assessed. Most questions utilized a corresponding five point Likert scale with space for free-text commentary. Categorical variables were analyzed with chi-squared tests and ordered logistic regressions using SAS (version 9.4; SAS Institute Inc., Cary, NC). 

Results: Thirty residents (68.2%) participated in the survey. Every post-graduate year was represented with an 86.7% (26/30) survey completion rate. In aggregate, most residents rated animal (88.5%, 23/26, p<0.0001) and cadaver based activities (80.8%, 21/26, p<0.002) as adequate to very adequate surrogates for assessing technical competencies. Conversely, virtual reality laparoscopic trainers (80.8%, 21/26, p<0.002) and endoscopic trainers (69.2%, 18/26, p<0.05) were rated as neutral to very inadequate surrogates. Among senior residents (clinical years 3-5), only 20% (2/10) rated upper-level simulation sessions as having greater than average value (p=0.06). Among all residents, a curriculum where simulation activities occur solely during junior and lab years was viewed favorable to extremely favorably (69%, 18/26, p<0.05). Subjective commentary reflected residents’ skepticism towards activities that potentially reduce time spent in the operating room, including simulation sessions during the senior operative years. 

Conclusion: Resident acceptance of surgical simulation is important in developing a robust curriculum to enhance operative autonomy over the course of training. Based on our institutional survey, residents support the use of tissue-based models and favor concentrating simulation activities in the early clinical years. These resident preferred curricular features have the benefit of introducing core operative techniques in a manner that most closely replicates the operating room experience while allowing advanced techniques to be mastered prior to performing them in actual patients. Further longitudinal evaluation is necessary to correlate participation in such curricula with operative skill and patient outcomes.

 

94.04 How the West was Won: West Texas as a Proving Ground for Prehospital Trauma Care Education.

Posted on January 26, 2017

N. Tully1, T. Dang1, M. Bhatia1, M. Aranke1, D. Vyas1  1Texas Tech University Health Sciences Center,Department Of Surgery,Lubbock, TX, USA

Introduction: Morbidity and mortality for trauma accidents in rural settings is nearly 3 times as high as in urban settings in the United States [1]. In both developed and developing countries, most morbidity due to trauma occurs in the prehospital period [2]. This increase in morbidity and mortality is, in part, due to a lack of appropriate critical care education of first responders in rural settings. The First Responder Trauma and Emergency Care Program aims to address this problem through implementation of a four-tiered trauma education program, which incorporates high-fidelity simulation, video-recorded debriefing, and retraining [4]. Previous studies show that this approach can be an effective strategy for teaching prehospital trauma management skills [5]. Additionally, this innovative educational program has been shown to be efficacious in improving first responder confidence in management of trauma [6].

Objective:

To assess the efficacy of a trauma care training program in West Texas.

Methods:

The First Responder Trauma and Emergency Care Program uses an interactive model of lectures, followed by breakout sessions where program participants practice the skills discussed in simulation environments. Simulation has previously been shown to be a useful tool in the training of trauma-related clinical skills [3]. This session was intended to test proof of concept of this type training being useful in West Texas, where sparse population and isolated location make trauma care uniquely challenging and similar in many ways to trauma care in the developing world. This study aims to assess whether the program is effective in improving specific skills related to trauma care.

Results: The change in confidence of medical students was significant; t(8)=0.005, p=0.013. While no other groups showed significant changes in competence or confidence, there was demonstrated improvement in all groups.

Conclusion: The initial assessments point towards the First Responder Trauma and Emergency Care Program being a worthwhile effort in the West Texas region. This pilot study also shows that the sessions are likely effective in improving confidence and competence of first responders, but further studies are needed to assess whether this program produces a significant difference in these areas. Future efforts will include recreation of this session in the cities of Lubbock and Amarillo, further analysis of data points collected from these additional sessions, and determination of what additional locations would benefit from these sessions in addition to analysis of the efficacy of the program in improving trauma care. A multicenter study of this trauma program has been conducted, the results of which are due to be presented at this meeting.

94.03 Astronauts’ non-technical skills during management of trauma on deep space missions to Mars

Posted on January 26, 2017

S. Yule1,3,4, J. Robertson3, A. Gupta4, R. Dias3, T. Doyle5, S. Lipsitz4, C. Pozner3, D. Musson2, D. S. Smink1,3,4  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Northern Ontario School Of Medicine,Thunder Bay, ON, Canada 3Brigham And Women’s Hospital,STRATUS Center For Medical Simulation,Boston, MA, USA 4Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 5McMaster University,Electrical And Computer Engineering,Hamilton, ON, Canada

Introduction:  Analysis of spaceflight medical events detail a number of surgical and trauma events. Inability to manage these during space flight represents a significant risk to astronaut crew health and can lead to mission failure. Effective coordination between the astronaut crew, mission control and ground-based flight surgeon is essential. In proposed deep space missions to Mars, crew may be in space for up to three years. In the event of a medical emergency, the possibility of returning to Earth or consulting with the flight surgeon via long distance communications may be challenging. In surgery, simulation training and non-technical skills (NTS) assessment tools ameliorate this risk. However, a valid simulation-training framework and objective measures of NTS are currently lacking for spaceflight. In order to develop these, we must first determine the survivability of potential space medical emergencies and the extent to which effective NTS in the early management of these conditions could save lives.

Methods:  This was a cross-sectional expert panel analysis, based on current NASA evidence of 80 potential medical conditions in space. A multidisciplinary panel of surgeons, health service researchers, astronauts, human factors scientists and space medicine practitioners were recruited. Panel members rated each of the 80 conditions using a 5-point Likert scale on three criteria: (i) utility of NTS in managing the emergency, (ii) survivability in space, (iii) ease of developing a quality simulation for training.

Results: A frequency-severity-skill matrix was developed from analysis of panelists’ ratings. From this initial analysis, we identified ten traumatic and medical emergencies (Table 1) that present the greatest opportunity for the development of simulation scenarios. Of specific interest are traumatic injuries such as pneumothorax, burns, lower extremity fracture, head injury and penetrating abdominal injury. Developing simulation training that emphasize NTS will ultimately increase survivability of these spaceflight medical events. Complete results of the matrix will be presented at the conference.

Conclusion: In-flight medical emergencies represent a significant risk to the safety and wellbeing of the crew, as well for the success of the mission. By involving surgeons, space medicine experts, astronauts, and human factors scientists we ranked all possible medical conditions in space and prioritized survivable traumatic injuries for inclusion in spaceflight NTS training curricula. This will support proficiency in medical event management on long-duration space exploration missions, such as mission to Mars.

 

94.02 Teaching Surgical Skills In A Resource Limited Setting:Massed Vs Distributed Practice, An RCT

Posted on January 26, 2017

R. Munyaneza1, R. Rivielo2, F. Ntirenganya1  1National University Of Rwanda,Surgery,Butare, SOUTHERN, Rwanda 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction: Teaching surgical skills has increasingly been preferred in the simulation laboratory than in the operative room for skills acquisition to surgical residents. However few studies investigating the adequate method of teaching have been done. Massed and distributed practices are important methods in teaching physical tasks and may be important in learning surgical skills.

Methods: : 32 residents and senior clerks in surgery were recruited and randomly assigned to massed group (3 hours training for 1 day) and distributed group (1 hour training per day for 3 days). They were taught ultrasound guided core needle biopsy on a high fidelity breast simulator. They all performed a test before and after the training and an evaluation of skill retention was done one month after completion of the training. Analysis of grades obtained was done and p value ≤ 0.05 was considered statistically significant.

Results:There was no statistically significant difference between the grades obtained by both groups in the pretest (p=0.726) and the posttest (p=0.635). Both groups performed better in comparison of the results obtained in the pretest and the posttest (p=0.000), there were no significant difference in the evaluation of skills retention after one month following the training between the two groups (p=0.273).

Conclusion:The results of this study showed that trainees retained the skill of ultrasound guided core needle biopsy on a breast simulator the same way if trained under a massed or distributed training schedule, both methods can be adopted in our settings for teaching surgical skills.

 

94.01 An Argument for Simulation-based Mastery Learning Education Courses for Practicing Surgeons

Posted on January 26, 2017

L. M. Baumann1,2, K. A. Barsness1,2  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H Lurie Chidren’s Hospital,Pediatric Surgery,Chicago, IL, USA

Introduction:  A number of congenital anomalies are amenable to advanced minimally invasive surgery (MIS) techniques.  Unfortunately, these procedures are rare, leaving surgeons with few opportunities to develop the necessary skills to safely perform the operations minimally invasively.  The majority of pediatric MIS training courses occur at annual conferences, with 4-8 hours of intensive training.  Best described as “exposure courses,” little data is available to support the benefit of these courses relative to the safe implementation of new skills.  The purpose of this manuscript is to determine the impact of an exposure course for advanced neonatal MIS skills on perceived comfort levels with performing advanced MIS operations independently.  

Methods:  A 4-hour hands-on course for advanced neonatal MIS procedures was held at an international surgical congress.  Course participants were practicing surgeons seeking to advance surgical skills in thoracoscopic tracheoesophageal fistula (tTEF) repair, thoracoscopic lobectomy (tLobe), and laparoscopic duodenal atresia (lapDA) repair.  Anonymous surveys regarding clinical practices and pre- and post-training perceived “comfort levels” for each procedure were completed by participants. Descriptive analyses were performed.

Results: Of 18 course participants, 17 completed pre- and post-course surveys.  Pre-course, the majority of participants had no prior experience with tLobe (59%) or lapDA (53%), and many had no experience with tTEF repair (35%).  Similarly, the majority were “not comfortable” with minimally invasive tTEF repair (59%), tLobe (65%), and lapDA repair (71%).  On post-course survey, the majority of surgeons were “likely to perform” these operations within 6 months.  Of the 6+ participants with no prior experience, 67%, 70%, and 56% were “somewhat or very likely” to perform tTEF, tLobe, and lapDA repair within 6 months.  Similarly, of the 10+ participants self-reportedly “not comfortable” with the MIS procedures, 70%, 73%, and 58% were “somewhat or very likely” to perform these procedures within 6 months. 

Conclusion: In conclusion, an exposure training course led to immediate perception of increased skills and confidence.  While these data may seem to support “exposure” courses, basic tenets of expert performance that demands deliberate practice in a distributed schedule, with ongoing formative and summative feedback, are typically not provided in exposure courses such as these.  Future course design should transition to a Mastery Learning framework in which regular skills assessments, milestones, and unlimited education time are prioritized, prior to implementation of the new skills. 

 

93.21 Tube Labeling as a Means to Eliminate Tubing Misconnections

Posted on January 26, 2017

S. I. Hill2,3, K. R. Dumon2, N. J. Hoke4, G. J. Bordi2,5, L. Owei1, D. T. Dempsey2; 1University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA 2Hospital Of University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA 3University Of San Diego, College Of Arts And Sciences, San Diego, CA, USA 4Hospital Of University Of Pennsylvania, Nursing Department, Perioperative Services, Philadelphia, PA, USA 5Hospital University Of Pennsylvania, Department Of Nursing, Philadelphia, PA, USA

Introduction:
Literature review of Pub Med, Google scholar and The Food and Drug Administration (FDA) suggests that most tubing misconnections lead to adverse events (70%) including death (24%). Abdominal tube misconnections (e.g. enteral feedings hooked to biliary t-tubes) or misidentification (e.g. jejunostomy catheter pulled instead of JP drain) is an important but underappreciated clinical problem. This study aims to examine tube-labeling as a solution to the problem of tubing misconnections.

Methods:
A tube labeling system for abdominal tubes, drains, and stents was developed by the unit based clinical leadership teams from perioperative services and the surgical inpatient units in November 2015 at our university hospital. Printed tube labels with high grade adhesive were placed in each OR, and surgical residents and attendings were educated and asked to place labels at the end of each abdominal operation in which tubes, drains and/or stents were placed. For seven months (January-July 2016) labeling compliance was tracked and surgical unit nurse satisfaction was assessed and postoperative tube misconnections were monitored.

Results:
Labeling compliance gradually increased to 65% after seven months. No tubes were mislabeled. Surgical unit nurse satisfaction was high; all nurses and surgeons interviewed felt this was an important quality improvement initiativeand the most common reason for surgeon noncompliance was “I forgot”. Despite lack of 100% tube labeling compliance, there have been no abdominal tube misconnections so far in 2016 (there were 3 in 2015).

Conclusion:
Routine intraoperative labeling of abdominal tubes, drains, and stents by the operating surgeon or resident may decrease postoperative tube misconnections. Incorporating a reminder into an OR checklist or debrief is likely necessary to achieve 100% surgeon compliance. Even with less than universal compliance, a tube labeling policy increases staff awareness of the important problem of tube misconnections and may help to eliminate this potentially dangerous mistake if tubes are labeled correctly.
 

93.20 Growth in Robotic Hernia Repair due to Reduction of Laparoscopic Approach, not from Open Surgeries

Posted on January 26, 2017

P. R. Armijo1, D. Lomelin2, D. Oleynikov1  1University Of Nebraska College Of Medicine,Surgery,Omaha, NE, USA 2University Of Nebraska College Of Medicine,College Of Medicine,Omaha, NE, USA

Introduction:  Advancements in technology have led to an increasing number of robotic surgeries over time, in a wide variety of procedures. The aim of this study is to evaluate the current national trends of open (OVHR), laparoscopic (LVHR) and robotic (RVHR) ventral hernia repair (VHR) and to account for the growth of robotic technique.

Methods:  This is a multi-center, retrospective study of patients who underwent VHR from January 2013 to September 2015. The UHC clinical database resource manager (CDB/RM) was queried using ICD-9 procedure codes for OVHR, LVHR and RVHR. Trends were evaluated between and within quarters (Q1 2013 to Q3 2015) and comparisons were made between OVHR and MIS approaches (which included both LVHR and RVHR), and within the MIS group. The last quarter of 2015 was excluded due to changing in the coding system. The data was analyzed using IBM SPSS v.23.0 using linear-by-linear association test.

Results:A total of 63,308 patients underwent VHR from 2013 to 2015 (OVHR: N=50,234; LVHR: N=12,293; RVHR: N=781). During this period, a significant increase of 2.54% was seen in OVHR compared to MIS approaches (graph 1). In the first quarter of 2013, OVHR accounted for 77.87% (N=4,584) of the procedures versus 22.13% of MIS (N=5,887). Whereas, an increase to 80.41% (N=4,183) of OVHR occurred in 2015, compared to a significant decrease of both LVHR and OVHR to 19.59% (N=5,202) in the same time frame (p=0.007). Likewise, an interesting trend was seen within MIS group. RVHR nearly tripled from 4.30% (N=56) in 2013 to 11.97% (N=122) in 2015; whereas LVHR decreased from 95.70% (N=1,247) to 88.03% (N=897) in the same period of time (p<0.001).

Conclusion:In the field of Urology and OB/GYN, growth in robotic surgery has converted open operations to MIS. From the data in this study, it appears that growth in RVHR has come from laparoscopic techniques, and not from open surgery as previously thought. Effects on cost and long term outcomes will need to be studied in order to better understand the impact of this trend.

 

93.19 Emergency General Surgery Transfers have Increased Mortality Risk

Posted on January 26, 2017

C. E. Reinke1, M. Thomason1, N. Rozario1, B. D. Matthews1  1Carolinas Medical Center,Department Of Surgery,Charlotte, NC, USA 2Carolinas Medical Center,Dickson Advanced Analytics,Charlotte, NC, USA

Introduction: Emergency general surgery (EGS) admissions account for more than 3 million hospitalizations in the US annually. Although EGS transfers who undergo surgery have been shown to have worse outcomes, EGS transfers who are managed non-operatively have not previously been studied.  We aim to better understand the characteristics and risk of mortality for EGS interhospital transfer (IHT) patients compared to EGS admissions from the Emergency Department (ED).

 

Methods: Using the 2002-2011 Nationwide Inpatient Sample we identified patients age ≥18 years with an EGS non-cardiovascular principal diagnosis (AAST EGS DRG ICD-9 codes) and urgent or emergent admission status.  These patients were classified into IHT patients and ED patients based on admission source.   Patient demographics, hospitalization characteristics, rates of operation and mortality were identified and compared between the two groups.  The risk of mortality was calculated for IHT patients compared to ED patients, both before and after adjusting for patient characteristics in a multivariable analysis. 

 

Results: From 2002-2011 there were an estimated 25,629,352 EGS admissions, 2% of which were IHTs.  The mean age was 59 years, 54% were female, and 46% were Medicare patients. Transfer patients were more likely to be white, to be female, have Medicare.  IHTs had higher rates of most comorbidities with the exception of AIDS, blood loss anemia, coagulation deficiency, and drug abuse.  Upper gastrointestinal tract and hepatobiliary diagnosis categories were the most common EGS diagnosis in both groups, but a higher percentage of ED admissions had colorectal, general abdominal, or soft tissues diagnoses compared to IHTs.  IHTs were more likely to undergo a surgery or procedure and had a higher mortality rate.  The odds of mortality were increased for IHTs, and remained elevated even after controlling for patient characteristics and EGS diagnosis (Table 1).

 

Conclusions: EGS patients who are transferred from another acute care hospital are at higher risk of mortality even after controlling for a wide range of patient characteristics.  They also undergo procedures and surgeries at a higher rate than ED patients.  Future studies to identify other contributing factors to this increased risk can identify opportunities for decreasing the mortality rate in EGS transfers.

93.18 The Readmission After Heart Failure (RAHF) Scale: Determining 30-Day Readmission Risk

Posted on January 26, 2017

B. L. Siracuse1, J. Sond1, K. Mahendraraj1, C. S. Lau1,2, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 3Rutgers University,Surgery,Newark, NJ, USA

Introduction: Congestive heart failure (CHF) affects over 5 million Americans, innumerable surgical patients, and accounts for over 1 million hospitalizations annually. The Affordable Care Act established the Hospital Readmission Reduction Program (HRRP) requiring the Centers for Medicare and Medicaid Services (CMS) to reduce payments to hospitals with excess readmissions as of October 2012. Identifying surgical and non-surgical patients at greatest readmission risk should permit the adoption of risk preventive strategies prior to admission or surgical therapy. This study sought to develop a predictive readmission nomogram that could identify CHF patients at higher readmission risk and permit the implementation of readmission risk reduction strategies.

Methods: Discharge data on 642,448 patients from New York and California (derivation cohort) and 365,359 patients from Washington and Florida (validation cohort) were abstracted from the State Inpatient Database (SID), a part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (2006-2011). Demographic and clinical characteristics of CHF patients readmitted were abstracted including age, gender, race, and medical comorbidities. The Readmission After Heart Failure (RAHF) Score scale was developed to predict readmission risk.

Results: Readmission rates for males and females were 10.04% and 8.83% for the derivation cohort and 9.69% and 8.62% for the validation cohort, respectively. Factors determined to be associated with increased risk of readmission after CHF hospitalization included age <65 (OR 1.14; 95% CI, 1.11-1.18), male gender (OR 1.13; 95% CI, 1.11-1.15), 1st income quartile (OR 1.09; 95% CI, 1.07-1.12), African American race (OR 1.34; 95% CI, 1.30-1.37), race other than African American or Caucasian (OR 1.10; 95% CI, 1.07-1.12), Medicare (OR 1.33; 95% CI, 1.29-1.38), Medicaid (OR 1.72; 95% CI, 1.65-1.78), self-pay/no insurance (OR 1.14; 95% CI, 1.07-1.22), drug abuse (OR 1.65; 95% CI, 1.57-1.73), renal failure (OR 1.37; 95% CI, 1.34-1.39), chronic pulmonary disorder (OR 1.15; 95% CI, 1.13-1.17), diabetes (OR 1.12; 95% CI, 1.10-1.14), depression (OR 1.08; 95% CI, 1.05-1.12), and fluid and electrolyte disorder (OR 1.03; 95% CI, 1.01-1.05). The RAHF Scale was created. When it was applied to the validation cohort, it explained 96% of readmission variability within the cohort.

Conclusions: The RAHF Scale reliably predicts an individual patient’s 30 day CHF readmission risk based on specific factors present at initial admission. Risk stratification models, such as the RAHF Scale, can identify high-risk surgical and non-surgical patients thereby permitting the implementation of patient-specific readmission-reduction strategies to improve patient care, reduce surgical complications, as well as reducing readmissions and healthcare expenditures. 

93.16 Is Umbilical Hernia or Diastasis Recti Associated with Increased Risk of Ventral Incisional Hernia?

Posted on January 26, 2017

M. L. Moses1, C. Hannon1, D. V. Cherla1, K. Mueck1, J. L. Holihan1, S. Millas1, C. J. Wray1, L. S. Kao1, T. C. Ko1, M. K. Liang1  1University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA

Introduction:
Despite the prevalence of umbilical hernia and diastasis recti in the general population, it is unknown if the presence of either increases the risk of developing a ventral incisional hernia (VIH).  We hypothesize that among patients undergoing abdominal surgery, individuals with an umbilical hernia or diastasis rectus have an increased risk of developing a postoperative VIH. 

Methods:
This was a retrospective study of all patients undergoing surgery for gastrointestinal cancer at a single institution from January 2011 to December 2015. These patients were chosen because of their high likelihood of having both preoperative and postoperative CT imaging. Inclusion criteria included all patients undergoing surgery with a periumbilical incision and both preoperative and postoperative CT scans. To ensure that the baseline umbilical hernias were not VIHs from previous operations, all patients with previous abdominal surgeries were excluded. The primary outcome was whether a VIH was visualized on postoperative CT scan. Primary outcome was compared by chi-square statistical analysis. 

Results:
A total of 159 patients met inclusion criteria and were followed for a median(range) of 41.7(21.7-79.3) months.  Prior to surgery, 93(58% of the included cohort) had a radiographic umbilical hernia and 67(42%) had a diastasis rectus.  Following surgery, patients with a prior umbilical hernia were more likely to have a VIH on postoperative CT scan (67/93,72% versus 26/66,40%, p<0.001) while patients with a preoperative diastasis rectus were not more likely to acquire a postoperative VIH (39/67,58% versus 56/92,61%, p=0.746).   

Conclusion:
Umbilical hernias but not diastasis recti are associated with an increased risk of developing a postoperative VIH.  In addition, the prevalence of ventral hernias seen on CT scans before and after abdominal surgery is substantial. Further studies are needed to determine if radiographically diagnosed hernias are clinically significant and to define the appropriate role of imaging in diagnosing and assessing abdominal wall defects.
 

93.15 Reducing Intra-operative Delays with Fidelity to the Surgical Safety Checklist

Posted on January 26, 2017

K. M. Masada1,2,3, K. T. Anderson1,2,3, M. Bartz-Kurycki1,2,3, J. E. Abraham1,2,3, J. Wang1,2,3, C. Shoraka1,2,3, M. T. Austin1,2,3, A. L. Kawaguchi1,2,3, K. P. Lally1,2,3, K. Tsao1,2,3  1McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),Houston, TX, USA

Introduction:  Although the surgical safety checklists (SSC) were introduced to improve morbidity and mortality, the pre-incision, or “timeout” phase, may provide additional benefits such as preventing intra-operative delays in the era of cost containment and increasing evidence of increased risk of prolonged anesthesia in children. Checklists may provide a unique opportunity to communicate potential concerns to improve operating room efficiency as well as patient safety. The purpose of this study was to evaluate intra-operative delays and correlate them with adherence and fidelity to the pre-incision SSC. 

Methods:  Trained observers evaluated SSC compliance during 3 observation periods between 2014 and 2016. Adherence (verbalization of a checklist item) and fidelity (meaningful completion of a checklist item defined a priori) were evaluated. Delays, categorized as missing equipment, malfunctioning equipment, human error, and medication issues were captured. A total pre-incision score, combining number of checkpoints adhered to, was given to each case with a maximum score of 16. Six checkpoints were selected for fidelity assessment. Descriptive statistics, logistic regression and Student’s t-test were used to analyze results. A p-value <0.05 was significant.

Results: Of the 582 cases observed, 17% (n=98) had at least one documented intra-operative delay. There were 145 total documented delays, the majority of which were related to missing (48%, n=70) or malfunctioning (32%, n=47) equipment. Human error, such as dropped equipment or mislabeling led to only 14% (n=21) of delays, while medication-related issues were 5% (n=7). Compared to cases without delays, cases with delays did not have a different mean total pre-incision score in any year. Mean adherence to all checklist items was 93% compared to 78% mean fidelity. Five of 6 fidelity items had lower scores in delayed cases, while 2 checkpoints demonstrated significant association (graph). Equipment concerns had the largest differential in fidelity of more than 20%.  

Conclusion: The pre-incision SSC is a communication tool, which offers an opportunity to discuss potential concerns and anticipated intra-operative needs. Mere adherence to the SSC does not appear to diminish intra-operative delays. However, meaningful completion (fidelity) to checklist items, especially those most likely to cause delays, such as equipment, may improve operating room efficiency and ultimately, patient safety.

 

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