75.09 How Far Have We Come? A Survey of U.S. Institutions From the SUS Committee on Academic Global Surgery

Posted on January 18, 2018

M. Boulos2, C. Q. Stephens2, E. Ramly1, B. Nwomeh3, S. Orloff4, S. Krishnaswami2  1Oregon Health And Sciences University,Department Of Surgery,Portland, OR, USA 2Oregon Health And Sciences University,Division Of Pediatric Surgery,Portland, OR, USA 3Ohio State University,Department Of Pediatric Surgery,Columbus, OH, USA 4Oregon Health And Sciences University,Division Of Abdominal Organ Transplant Surgery,Portland, OR, USA

Introduction:

Global surgery has recently gained prominence within public health, and has growing interest among surgical trainees. Despite variable endorsement within academia, we hypothesized that overall Academic Global Surgery (AGS) work and institutional backing has increased over the last decade.

Methods:
We conducted a longitudinal study comparing two surveys of U.S. academic surgery department involvement in AGS. In 2009, a SUS and AAS survey explored AGS efforts, institutional support, perceived benefit to individuals and institutions, and next steps for field advancement. A follow-up survey was conducted in 2017 to evaluate interim change. Surveys were sent to program directors, chairpersons and faculty in global surgery using Survey Monkey©. Comparisons were analyzed by Chi-square and Fisher’s exact tests with significance at p≤0.05.

Results:

In 2017, 118 respondents initiated the survey compared to 117 in 2009. International partnerships increased significantly (60 vs 38%, p<.001), with programs spanning the globe and doubling in Africa (65 vs 30%, p=.001). Most AGS efforts remained structured as short-term clinical volunteerism (57 vs 47%, p=.41), with a notable rise in clinical research (57 vs 20%, p=.005) and new capacity building initiatives (49%). While trainee participation increased (44 vs 23%, p=.008), faculty involvement did not.

Significant changes in institutional support were reported, with increases in long-term time allowances and a 2-fold growth in internal funding (Table 1). Extramural funding also notably expanded. While credit toward academic promotion was more common, most institutions still had no structure to recognize faculty efforts. Significant increases were found in perception of individual professional enhancement and improvement of U.S. trainee education through AGS, but not in benefits to the institution. Perception of low and middle-income (LMIC) trainee benefit (74 vs 84%, p=.08) and provision of unavailable clinical care (64 vs 76%, p=.08) remained high. Priorities for future work included training of local workforces (94%) and validation of AGS through development of formal career tracks with contractual and financial support (84%).

Conclusion:
Over the past 8 years, AGS programs increased significantly and had provision of longer time allowances and internal funding. However, many departments remain without formal structure to facilitate longitudinal faculty efforts, despite acknowledged benefit to U.S. and LMIC trainee education. Further growth of AGS will require a clear delineation of the benefit to U.S. institutions, as ongoing institutional support will ensure sustained faculty involvement, thus enabling AGS to more closely focus on improving LMIC surgical capacity.

75.08 Can a Haptic Robotic Train New Interns to Place Central Venous Lines?

Posted on January 18, 2018

C. C. Sonntag1, M. A. Yovanoff3, D. F. Pepley2, R. S. Prabhu5, S. R. Miller4, J. Z. Moore2, D. C. Han1  1Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA 2Penn State University,Department Of Mechanical And Nuclear Engineerging,University Park, PA, USA 3Penn State University,Department Of Industrial Engineering,University Park, PA, USA 4Penn State University,Department Of Engineering Design And Industrial Engineering,University Park, PA, USA 5Penn State University,Department Of Engineering Design,University Park, PA, USA

Introduction: Ultrasound guided central venous catheterization (USCVC) training is typically performed using mannequin simulators that cannot simulate anatomic variations in vessel depth and position. Mannequin training also requires the presence of a preceptor to provide real time meaningful feedback to the learner. A virtual reality haptic robotic simulator that provides anatomic variation and immediate qualitative feedback has been previously validated. The goal of this study was to assess the effectiveness of the robotic simulator as a new intern training device using Verification of Proficiency (VOP) testing as the outcome measure.

Methods: Resident USCVC training curriculum currently consists of an introductory video, didactic instruction, procedure demonstration, and three simulation sessions prior to VOP testing.  New surgical interns were randomly assigned to either robotic (n=13) or mannequin (n=13) training, and all 26 interns performed a pretest USCVC on the same mannequin that was used for training. Both the first and second simulation sessions consisted of ten ultrasound guided venous aspirations on their assigned training modality. Feedback was provided by either the robotic simulator (robotic group) or an experienced preceptor (mannequin group).  The training mannequin was used in the third session by both groups. This session consisted of two USCVC with feedback by an experienced preceptor. VOP testing was performed on a mannequin with vessel depth and position that was dissimilar to the mannequin used for simulator training. A standardized rubric grading system was used by a single experienced educator to assess VOP performance. Two-way mixed ANOVA was used to evaluate results.

Results: Baseline demographics and pre-test time to insertion were not significantly different between groups. All robotic simulation residents (13 of 13) passed VOP testing on their first attempt, compared to 92% of residents trained on mannequin simulation. Reason for the exam failure in the mannequin group was unintentional arterial access. Average time to perform ultrasound guided venous aspiration for mannequin trained residents was 134 seconds, compared to 86 seconds for robotic trained residents training (p = 0.07).

Conclusion: The virtual reality haptic robotic simulator for USCVC demonstrated improved results compared to standard mannequin training with respect to first time pass rate on VOP testing. Interns who used the robotic simulator showed a faster time to perform USCVC compared to mannequin testing, although this did not quite reach statistical significance. In addition to the ability to simulate anatomic variations, another potential advantage of the robotic simulator for USCVC is the immediate

75.07 Utilizing Technology for Global Surgery: A Survey of the West African College of Surgeons

Posted on January 18, 2018

A. Ashok1, C. Stephens1, E. Ameh2, M. Swaroop3, E. Yang1, S. Krishnaswami1  3Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA 2National Hospital,Abuja, FEDERAL CAPITAL TERRITORY, Nigeria

Introduction:

A previous AAS sponsored workshop demonstrated that high-income country (HIC) participants had strong interest in using Information and Communication Technology platforms (ICT) to facilitate global surgery collaborations. However, access, usage, and utility of ICT in Low-and Middle-Income Countries (LMIC) was unknown. We hypothesized that LMIC surgeons shared similiar interest in using ICT to facilitate international collaborations and education initiatives.

Methods:  

We conducted a survey of members of the West African College of Surgeons (WACS). Topics included computer and internet access/utilization, familiarity with ICT, such as social media (SM), virtual document sharing platforms (VDS), virtual meeting applications (VM), and learning management systems (LM), and interest in ICT adoption. English and French surveys were distributed through RedCap™ and in paper at the WACS and Pan African Pediatric Surgical Association conferences. Statistical analyses were done on STATA 14 using chi-squared tests, with Bonferroni corrections.

Results:

In total, 83 individuals began the survey, and 71% completed all sections. Respondents came from 9 countries (80% were faculty) and were equally split in years of practice (50% > 10 years). All respondents reported computer access, using laptops (91%), smartphones (82%) and tablets (62%). A significantly greater proportion (95%) of participants used SM compared to all other modalities (p<0.001). Commonly used SM platforms included Facebook, LinkedIn and WhatsApp, with 77% using them for professional reasons and 57% for education. VDS was used by 60% of participants, 73% of whom used it for education. The utilization of other ICTs was lower (VM 43%, LM 32%). Unreliable wifi hindered every ICT, less often SM (41%) and VDS (23%), and more commonly VM (64%) and LM (52%). Despite this, VM was typically used in international collaboration (79%), as compared to SM (42%, p=0.007), VDS (42%, p=0.007), or LM (32%, p=0.001, see figure). The vast majority of respondents (98%) expressed interest in using ICT to support local and international collaboration, with SM favored in medical education (85%) and VDS favored in collaborations (86%).

Conclusion:

ICT platforms have potential for supporting bidirectional education initiatives and international collaborations in resource limited areas, with surgeons in both HIC and LMIC expressing high levels of interest. Given the penetrance and reliability of SM and VDS, despite relative underusage and, at times, unreliable and limited wifi, there is significant potential for increased use of both platforms. Workshops providing instruction on ICT use are warranted to support the expansion of ICT use in global surgical collaborations. 

 

75.06 Evaluating Mobile Information Display System in Transfer of Care Scenarios

Posted on January 18, 2018

S. Ganapathy1, K. A. Berberich1, A. N. Kreiner2, M. McCarthy1  1Wright State University,Department Of Industrial And Human Factors Engineering; Department Of Trauma Care And Surgery,Dayton, OH, USA 2Air Force Research Lab,Human Performance Wing,DAyton, OH, USA

Introduction:
Transfer of care continuum is highly dynamic in nature and there are multiple complexities associated with man-man interaction and man-machine interaction. During transfer of patient care, adequate information related to the patient must be communicated very quickly and precisely. Providing the receiving emergency department with patient vitals and pre-hospital procedures that occurred during the EMT ride could allow for enhanced preparation and improved communication during the transfer process thereby being beneficial to the patient’s health. This paper focuses on designing and evaluating the usability of information presentation for a tablet device and the use of such device to improve efficiency during the transfer of care process. This could potentially help emergency department better prepare for the incoming patient.

Methods:
The experiment was conducted on a 7" Samsung tablet. The pool of participants was 16 nursing or medical students from WSU's nursing program and Boonshoft School of Medicine). A training period was provided to familiarize the participants with the display screens they would be seeing during the experimental scenarios. During the experimental phase, participants were asked to navigate through four different simulated transfer of care scenarios using a 7-inch tablet and create an action plan for when the patient would arrive.

Results:
Results indicated that basic information displays on the use of mobile devices for transfer of care could provide faster preparation response times in one and three patient-simulated scenarios. Results indicate that there were significant differences for simple and complex scenarios (p<0.0001) and for basic and advanced information displays (p=0.0474). An analysis of variance indicated there was a significant difference in the response time by situation (p<0.0001). Investigating the response times to create an action plan and SUS scores for display type, scenario, and type of medical personnel helped to identity the best information display design for patient vitals in a transfer of care.

Conclusion:
The fast paced, highly unpredictable environment of transfer of cares results in critical information being condensed down to be verbally conveyed as quickly as possible. Reducing patient information can result in errors, and even negative outcomes for the patient. Investigating the best information display resulted in the simpler displays having a faster response times compared to the advanced. Results also showed that the higher the usability score the quicker the response time suggesting future studies focus on high usability. This study can also help in training novice users the methods to prepare for complex scenarios during transfer of care.

75.05 The Next Generation of Global Surgeons: Aligning Interest with Early Access to Global Surgery Education

Posted on January 18, 2018

E. M. Scott1, R. E. NeMoyer1, D. H. Blitzer3, J. S. Hanna1, Z. C. Sifri2, V. H. Gracias1, G. L. Peck1  1Robert Wood Johnson – UMDNJ,New Brunswick, NJ, USA 2New Jersey Medical School,Newark, NJ, USA 3MedStar Union Memorial Hospital,Baltimore, MARYLAND, USA

Introduction: While interest in global surgery appears to be increasing among medical students, little information is available regarding student perceptions of global surgery or level of interest in participation. In addition, limited data exists regarding availability and access to global surgery electives for students. This study investigates the influence of student demographics on interest in global surgery, the extent that global surgical burden education has been integrated into medical education curricula across the United States (US), and availability of global surgery electives.

Methods: An anonymous online survey was provided to the American Medical Student Association, who then distributed the survey via email and social media to current medical student members. Descriptive data was compiled regarding interest in and access to global surgery programs; demographic data was analyzed using chi-square testing for categorical variables.

Results: A total of 205 complete surveys were included in analysis. Over 85% of respondents were born in the US, however, 47% reported at least one parent born outside of the US. Respondents were predominantly located in the northeast (70%). A statistically significant association was identified between medical school year and reported interest in global surgery, with a higher proportion of those interested being in their pre-clinical years. A majority (61%) expressed interest in participating in global surgery programs, with top reasons reported as gaining an understanding of international health systems and sociocultural determinants of health. Collectively, 84% of respondents reported that global surgery issues are rarely or never addressed in their required medical school curriculum. Over half of respondents answered, “I don’t know,” when asked if their school offers a global surgery focus or electives within the global health department. Reported barriers to participating in global surgery programs included: funding (87%), scheduling constraints (65%), and language proficiency (51%).

Conclusion: Disparities in global surgery have emerged as an area of interest for medical students. This concern appears to extend beyond country of origin with a curiosity regarding the sociocultural determinants of health, suggesting a genuine commitment to social responsibility.  In addition, the data suggests that introduction to global surgery issues may be most effective during pre-clinical years so that students may incorporate potential interest with their clinical aspirations. The data also reveals that many students lack meaningful exposure to global surgery concepts, and are unaware of elective opportunities within their institution. Further study is needed to identify barriers to providing global surgery education either within core curriculum requirements or as electives. Early exposure to issues in global surgery is essential in engaging the next generation of surgeons to address these disparities.
 

75.04 The Malawi Trauma Score: A Model for Predicting Trauma-Associated Mortality in a Resource-Poor Setting

Posted on January 18, 2018

J. R. Gallaher1, M. Jefferson1, C. Varela2, B. Cairns1, A. Charles1,2  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Surgery,Lilongwe, , Malawi

Introduction:
Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. Current tools for predicting trauma-associated mortality are often not applicable in low-resource environments due to a lack of diagnostic adjuncts. This study sought to derive and validate a model for predicting mortality that requires only a history and physical exam. 

Methods:
We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi from 2011 through 2014. Using statistical randomization, 80% of patients were used for derivation and 20% were used for validation. Logistic regression modeling was used to derive factors associated with mortality and the Malawi Trauma Score (MTS) was constructed. The model fitness was tested. 

Results:
62,425 patients were included. The MTS is tabulated based on initial mental status (alert, responds to voice, responds only to pain or worse), anatomical injury location, the presence or absence of a radial pulse, age, and sex, with a total possible score of 32. A mental status exam of only responding to pain or worse, head injury, the absence of a radial pulse, extremes of age, and male sex all conferred a higher probability of mortality. The ROC area under the curve for the derivation cohort and validation cohort were 0.83 and 0.84, respectively. A MTS of 25 confers a 50% probability of death (Figure 1).

Conclusion:
The MTS provides a reliable tool for trauma triage in sub-Saharan Africa and helps risk stratify patient populations. Unlike other models previously developed, its strength is its utility in virtually any environment, while reliably predicting injury- associated mortality. 
 

75.03 Can They Stop the Bleed? Evaluation of Tourniquet Application by Laypersons with Reported Training

Posted on January 18, 2018

J. C. McCarty1, M. A. Chaudhary1, E. J. Caterson1,4, S. A. Goldberg2, M. L. McDonald1, C. Goolsby3, A. Haider1, E. Goralnick2  3Uniformed Services University Of The Health Sciences,Military & Emergency Medicine,Bethesda, MD, USA 4Brigham And Women’s Hospital,Division Of Plastic Surgery, Department Of Surgery, Harvard Medical School,Boston, MA, USA 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Department Of Surgery, Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Emergency Medicine, Harvard Medical School,Boston, MA, USA

Introduction: Uncontrolled hemorrhage is an important cause of preventable death. With the increasing incidence of mass casualty events in western nations as a result of urban terrorism, several initiatives have been launched to empower laypersons to act as first responders and perform hemorrhage control (HC) including but not limited to the ACS “Stop the Bleed” campaign in the United States, Just-in-time point of care education, and web-based education. A central tenet of these is application of extremity tourniquets. This study assessed laypersons’, who self-reported prior training, ability to control bleeding with a tourniquet.

 

Methods: Employees of a major National Football League stadium participated in this study assessing ability to apply a Combat Application tourniquet (CAT) in an emergency. As a subgroup analysis of a larger study, participants who self-reported prior: 1) first aid (FA) training or 2) FA + HC training were included and presented an emergency scenario requiring tourniquet application on a mannequin. Correct application was assessed by time to application and appropriate tourniquet tightness. Prior to this, we obtained demographic data including open-ended questions on type of training participants had received and administered a survey to assess likelihood to help in a scenario requiring HC and comfort level in effectively controlling hemorrhage. The effect of FA training compared to FA + HC training was analyzed using Chi-square to compare correct tourniquet application and Mann-Whitney U test to compare reported likelihood to help and comfort level in HC.

 

Results: 206 participants were included. Overall, only 27% correctly applied a tourniquet. There was no difference in correct tourniquet application between those reporting just FA training and those reporting prior FA + HC training (table). However, the likelihood to help in an emergency and reported comfort level to effectively control bleeding of those participants with prior HC training was significantly higher than those with just FA training (table). Within the open-ended questions, no participants reported formal ACS “Stop the Bleed” training.

 

Conclusion: Despite self-reported prior training, a great majority of participants were unable to correctly apply a tourniquet. Prior reported HC training was associated with an increase in these laypersons intention to act to control bleeding, but it did not improve correct tourniquet application compared to those with just FA training. As work continues to identify the most effective method of layperson empowerment to act as effective first responders, these findings highlight the importance of high quality hemorrhage control training with proven long term retention.

75.02 Eye-tracking in Educational Assessment: An Automated Procedure to Define Dynamic Areas of Interest

Posted on January 18, 2018

E. Fichtel1, J. Park2, S. Parker3, N. Lau1, S. D. Safford2  1Virginia Tech,Grado Department Of Industrial And Systems Engineering,Blacksburg, VA, USA 2Virginai Tech Carilion School Of Medicine,Surgery,Roanoke, VA, USA 3Virginia Tech Carilion Research Institute,Roanoke, VA, USA

Introduction:
Quality of assessment in medical education impacts training efficiency and patient outcomes. Eye tracking has demonstrated potential to provide unobtrusive and valid assessment of surgical skills by highlighting where experts and trainees focus during critical periods of surgical procedures. The locations of the expert eye-gazes can be used to define the Areas of Interest (AOIs) which can serve as evaluation criteria for where novices should focus. That is, eye-tracking provides a means to determine whether novices observe the same fields as the experts. However, when eye-gazes of experts are changing constantly over the course of a procedure, defining the AOIs can be time consuming and unnecessarily subjective because commercial software rely on the evaluator to specify the AOIs manually. To improve eye-tracking assessment, we developed a procedure that can be easily automated with common scripting language (e.g., R, Python) for defining dynamic AOIs for data analysis.

Methods:
The procedure for generating dynamic AOIs was developed with eye gaze samples collected from three expert surgeons viewing videos of laparoscopic cholecystectomy on a computer. Raw data on when (i.e., timestamps) and where (i.e., coordinates) expert gazes fell on the monitor was exported and using R statistics software the dynamic AOIs were defined. The R script removed invalid data (e.g., eye gaze outside of the monitor), and executed a loop to specify a circular-shaped AOI for every predefined time interval. The location and size of AOI center were based on the eye-gaze of an expert and 3 degrees of visual angle, respectively. The R script outputted a text file that was imported into a commercial software for quantitative eye-gaze analysis. At this exploratory analysis stage, we performed an ANOVA to test whether eye-gaze agreement between three expert surgeons would be lower for 10 videos with than 9 without adverse events.

Results:
This procedure created dynamic AOIs that closely resembled the heat map of expert eye gazes in the commercial eye-gaze analysis software (Figure 1), lending credibility to the validity of the procedure. Further, ANOVA indicated a significant decline in agreement between experts for videos with adverse events (F(1, 35)=10.02, p=.003), suggesting the dynamic AOIs were sensitive to change in complexity between surgeries.

Conclusion:
Our method of automatically generating dynamic AOIs can alleviate labor and subjectivity of the evaluators in manually defining AOIs for analysis. Future work will introduce dynamic AOI shapes to reflect complex environment in surgery. Our method should improve efficiency, sensitivity and reliability of analyzing eye-gaze in dynamic surgical environments. 
 

75.01 Utilizing Nurse-focused Simulation Sessions to Decrease Patient Refusal of VTE Chemoprophylaxis

Posted on January 18, 2018

L. J. Kreutzer3, A. D. Yang2,3, D. B. Hewitt3,4, K. Y. Bilimoria2,3, J. K. Johnson2,3  2Feinberg School Of Medicine – Northwestern University,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA 3Feinberg School Of Medicine – Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 4Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction: Venous thromboembolism (VTE) is the leading cause of preventable inpatient death. VTE prophylaxis for moderate to high risk patients includes chemoprophylaxis; however, patients who refuse prophylaxis increase their VTE risk. Studies suggest that nurses can influence patient compliance with VTE prophylaxis. We previously conducted nursing focus groups at one hospital and found that they felt ill-equipped to handle patient refusals of VTE chemoprophylaxis. Our objective was to assess the effectiveness of a structured simulation session designed to equip nurses with skills to handle conversations with patients refusing VTE chemoprophylaxis.

Methods: Based on the findings from our qualitative study, we developed a 20-minute interactive in-person patient VTE chemoprophylaxis refusal simulation (Figure) as part of a larger VTE Prophylaxis Improvement Bundle. The simulation session goals were to 1) discuss the perspective of inpatients who refuse VTE chemoprophylaxis, 2) equip nurses with strategies to address patient refusals, 3) provide opportunities for nurses to learn from each other, and 4) to practice the nurse-patient conversation around VTE chemoprophylaxis refusal. After a brief brainstorming session discussing reasons why patients refuse VTE prophylaxis, nurse participants role-played as both the nurse and patient in a scenario where a patient refuses VTE chemoprophylaxis. The facilitators then debriefed the entire group of nurses to discuss effective strategies to respond to patient concerns. Participants then switched roles and repeated the role-play. Nurses received a reference sheet on effective strategies to respond to patients who decline VTE prophylaxis. We evaluated nurses’ perceptions of the utility and effectiveness of the experience with a post-session survey.

Results:We conducted 17 patient refusal simulation sessions including a total of 122 nurses from 4 inpatient units. After the simulation session, 98.4% of nurses felt ‘Quite a Bit’ or ‘A Great Deal’ able to speak with patients refusing VTE chemoprophylaxis compared to 76.2% pre-intervention (P<0.001). Furthermore, 94% of nurses intended to change their practice as a result of the session. Attendees translated lessons learned as they returned to their units: “After the session, I saw a lot more confidence when nurses were explaining the benefits of the medication to help prevent VTE.” – Unit Nurse Manager

Conclusion:A brief, focused interactive simulation session met an educational need and improved nurses’ ability to discuss VTE prophylaxis with patients. Future efforts will focus on expanding the initiative across our hospital system by integrating the sessions into the nursing education curriculum.

 

57.20 A Cadaver-Based Enteroatmospheric Fistula Model for Negative Pressure Therapy Training

Posted on January 18, 2018

A. Coleoglou Centeno1, C. B. Horn1, M. M. Frisella1, C. M. Donald1, G. V. Bochicchio1, S. R. Eaton1, J. P. Kirby1, L. J. Punch1  1Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:
Enteroatmospheric fistulas (EAFs) are associated with the need for complex wound care. Negative Pressure Therapy (NPT) is a helpful adjunct in management of complex wounds. The use of NPT in the management of an EAF allows for both enhanced wound care as well as control of fistula efflux, but is technically difficult to apply. As part of a Visiting Preceptorship in Acute Care Surgery, we developed a cadaver-based model for training of nurse practitioners (NPs) and physician assistants (PAs) in NPT application to EAFs.

Methods:
The training model was developed for use in a hands-on application of NPT on an EAF using a cadaver model.  The model was prepared by performing a midline laparotomy. Sigmoid colon was mobilized and ligated proximally. The distal bowel was cannulated with plastic tubing which was secured to the bowel and passed through the abdomen through a separate stab incision. This was connected to dilute solution of methylene blue mixed with saline. An additional resection of skin and fat was done to create a complex surrounding wound. We then performed a primary fascial closure and exteriorized the colon, maturing the edges of the bowel to the fascia thus simulating an EAF. Groups of two PAs or NPs along with course faculty applied the wound NPT to the EAF model. 

Results:
A cadaver based model for EAF was created and NPT was successfully applied by the course participants. All fistulas were successfully isolated with a barrier ring, sponge and ostomy bag (figure 1).

 

Figure 1. 1a. EAF model. Note exposed loop of sigmoid colon 1b. EAF model demonstrating methylene blue saline efflux. 1c. EAF model with NPT and ostomy appliance. Note cannula containing methylene blue tinted normal saline.

Conclusion:
We developed a cadaver-based EAF model for NPT training. This model could potentially impact practice by allowing all members of the surgical team to improve their application techniques. We acknowledge limitations to the model such as lack of pre- and post- course comparison and need for competency evaluation. Another limitation to the model could be its standardized implementation as a training system due to the costs and need for laboratory facilities. Future aims include further evaluation of the model’s impact on participant’s competence and confidence.

57.19 Global Health Preparation: Surgery and Anesthesia Simulation

Posted on January 18, 2018

D. M. Langston1, M. Eskendar1, F. M. Peralta1, A. Doobay-Persaud1, N. Issa1, S. Galvin1, M. Swaroop1  1Northwestern University,Chicago, IL, USA

Introduction:
Five billion people lack access to safe, quality, and timely surgical healthcare. Basic surgical and anesthesia care can and should be provided by general practitioners in low resource settings. Training of these providers through simulation, a validated tool in educational programs for resident training, is a viable platform to impart surgical and anesthesia skills. No research is available, however, on the impact of basic skills simulation on preparedness for clinical care in global health field experiences, specifically involving surgery and anesthesia care. In preparation for a global health rotation, a team based simulation session was designed for non-surgical and anesthesia residents to evaluate the ability of simulation based learning to optimize knowledge, skills, and confidence levels as these relate to surgery and anesthesia care.

Methods:
Didactic and experiential training stations were developed based on six common surgical and anesthesia conditions identified by surgery and anesthesia global health faculty. Participants completed a pre- and post- self-assessment test utilizing a 3-point Likert Scale. Results were compared to evaluate the effectiveness of training and improvement in self-reported confidence in skill performance. 

Results:
Thirteen non-surgery and anesthesia resident physicians from 5 specialty areas participated in the training. All resident physicians spent 30 minutes at each of the 6 stations while being mentored and then monitored by surgery and anesthesia attending and resident physicians.  The participants who completed the post-test (n=13) considered the training either useful (85%, n=11) and/or of excellent quality (69%, n=9).  At the completion of the session, most trainees felt very comfortable performing intravenous line placement (92%, n=12), bag mask ventilation (100%), and incision and drainage (100%). Trainees felt the least comfortable performing laryngoscopy (23%, n=3) and conscious sedation (46%, n=6).

Conclusion:
Simulation for non-surgery and anesthesia resident trainees anticipating a global health experience is feasible and easily implemented. There continues to be a paucity of basic surgery and anesthesia care in low resource settings. Simulation training is a validated method to train not only general practitioners in basic surgery and anesthesia care, but also non-physician providers.
 

57.18 Video Gaming Influence on Technical Abilities Amongst Surgical and Non-Surgical Residents.

Posted on January 18, 2018

J. Lam1, C. Maeda1, T. Suzuki1, T. Pham1, D. Bernstein1, B. Sandler1, G. Jacobsen1, S. Horgan1  1University Of California – San Diego,Minimally Invasive Surgery,San Diego, CA, USA

Introduction:  Video games are ingrained into popular culture. They have been a strong presence for several decades and are a staple of modern day society. It has been established that having skill in video gaming correlates with improved skill in laparoscopic surgery. However, there has not been much data collected on the types of video game genres that are played, and if there is a belief that video games improve your ability to perform technical procedures. We hypothesize there may be a difference between surgical vs nonsurgical specialties regarding the type of video games that are played, as well as the amount of time dedicated to gaming. Our secondary aim is to assess if having a history of gaming effects perceived ability to perform technical procedures.

Methods:  A questionnaire was provided to surgical (n=45) and non-surgical residents and fellows (n=50), to assess video gaming experiences.  Analysis of demographic data, past and current gaming experience, and preference of genre was performed. Statistical analysis comparing surgical and non-surgical groups was performed using Chi-square test. 

Results: There were no significant demographic differences between the surgical and nonsurgical groups. Both groups had similar distribution in age, gender, and post-graduate year (PGY). The top three genres of video games played in the surgery group were roleplaying games (21%), shooter games (17%), and strategy games (12%). The top three genres in the non-surgical group were shooter games (19%), role-playing games, (18%), and fighting games (13%). There was no statistical difference in the genres of video games played by the two groups. In comparing the surgical and nonsurgical groups, there was a statistical difference in the belief that video gaming improved your technical ability (p-value = 0.036). Also, the average maximal amount of hours played per week was higher in those who believed that video games improved their technical ability (median 20 hrs/week). 

Conclusion: Surgical and non-surgical residents have similar patterns of video game play and types of video games that are played. However, surgical residents feel that their video gaming experiences improve their technical abilities. Also, increased gaming history correlated with perceived improvement of technical skills in performing procedures in both groups.

 

57.17 The Use of Virtual Humans for Team Training in the Operating Room

Posted on January 18, 2018

W. Goering1, J. W. Menard1, A. Deladisma1, M. Dimachk1, J. Wood3, B. Lok3, S. Lampotang4, A. Wendling2, A. Cordar3, D. S. Lind1  1University Of Florida-Jacksonville,General Surgery,Jacksonville, FL, USA 2University Of Florida-Jacksonville,Anesthesia,Jacksonville, FL, USA 3University Of Florida-Gainesville,Computer & Information Science & Engineering,Gainesville, FL, USA 4University Of Florida-Gainesville,Anesthesia,Gainesville, FL, USA

Introduction: Time constraints limit the ability to bring all OR team members together simultaneously to practice group communication skills. We hypothesize that virtual humans (VHs) can model behavior and scenarios for healthcare providers to learn communication and teamwork skills in the operating room (OR).  Therefore, we constructed and piloted an interactive team training exercise involving multiple VHs that represent essential OR team members.  To determine the initial face validity and realism of the VH interaction, volunteers participated in a surgery safety checklist scenario with the virtual team members.

Methods: Three virtual human teammates were assembled using a 40 inch 1080 pixel television mounted on a rolling stand with an HDMI connection to a Dell computer with Microsoft Kinect 2 software. The setting for all of the interactions was an actual OR in the outpatient surgical center (OSC) at the University of Florida – Jacksonville. The verbal responses of the VHs were controlled by a Wizard of Oz technique but VHs displayed normal speech, eye contact, facial expressions and movements when interacting with participants.

Results: Eleven medical professionals (4 Surgeons, 3 Nurses, 2 Medical Students and 2 Anesthesiologists) volunteered to participate in the mixed reality scenario.  Following the VH simulation activity, participants completed a survey regarding the face validity and realism of the interaction.

Conclusion: We created an interactive Virtual Human scenario aimed to teach and enhance communication skills in the operating room.  A pilot study with medical students, nursing, anesthesia, and surgery personnel demonstrated high face validity for the interaction with the virtual teammates.  The VHs were perceived by human teammates as real OR team members in the surgical safety checklist scenario and if generally applicable, may be useful for healthcare providers from diverse backgrounds to enhance team communication skills to improve patient safety

 

57.16 A Novel Cadaver-Based Model for Negative Pressure Therapy Training

Posted on January 18, 2018

C. B. Horn1, A. Coleoglou Centeno1, M. M. Frisella1, C. M. Donald1, G. V. Bochicchio1, S. R. Eaton1, J. P. Kirby1, L. J. Punch1  1Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:  Negative pressure therapy (NPT) is an increasingly important tool in the healing and management of soft tissue injuries, infections and wounds. However there are few hands-on training models available to teach the necessary skills for the safe and effective application of NPT.  As part a Visiting Preceptorship in Acute Care Surgery, we attempted to develop a cadaveric model, for use in training on NPT application.

Methods: The course consisted of didactic instruction by practicing physicians, operating room demonstration of NPT application and a hands-on laboratory consisting of cadaveric models of common scenarios where NPT could be applied. Two cadavers were prepared for each course. Each cadaver received a 10 centimeter laceration to the right leg, a 10cm x 3cm x 3cm debridement to the right inguinal region, medial and lateral left leg fasciotomies and a 15 x 6 superficial lesion. One cadaver received a laparotomy and was simply left open. The other cadaver received a midline laparotomy with cannulation of the bowel and debridement of the abdominal wall soft tissue so as to create an enteroatmospheric fistula (EAF) with subsequent closure of the fascia. Teams of two physician assistants (PAs) or nurse practitioners (NPs) and course facilitator applied NPT to all injuries. Course surveys were completed by all participants.

Results: Wounds were successfully created to simulate skin graft donor sites (figure 1), necrotizing soft tissue infections post debridement, partially closed fasciotomies (figure 2), open abdomens, lacerations and EAF (figure 3). NPT was successfully applied to all models by participating PA and NPs.  All 9 (100%) participants completed course surveys; 8 (88.9%) participants stated that the course would change their clinical care; 9 (100%) participants rated the lab as “excellent” overall. 

Figure 1. 1a. Lower extremity skin donor site model. 1b. Partially closed fasciotomy model. 1c. Enteroatmospheric fistula model. Note exposed loop of small bowel. 

Conclusion: We have developed a cadaveric model for use in NPT application training for a variety of clinical situations. The initial response to the training was positive, however we acknowledge significant methodological limitations, including lack of pre- and post- course comparison and lack of evaluation of NP and PA competency. Future work will aim to evaluate this model’s effect on trainee competence.

 

57.15 Surgical Skills Olympiad: A Four-Year Experience in a General Surgery Residency

Posted on January 18, 2018

A. D. Caine1, A. Kunac1, J. Schwartzman1, A. M. Merchant1, D. H. Livingston1  1Rutgers New Jersey Medical School,General Surgery,Newark, NJ, USA

Introduction:

Resident competition has been shown to increase usage of simulators for skills training and resident performance on simulation tasks. We examined the four-year experience with our “Surgical Skills Olympiad” at a large academic surgical residency in the Northeast. We hypothesize that residents perform better at Olympiad tasks since its implementation due to the competitive nature of the event.

Methods:

Surgical Olympiad is a yearly competition between teams formed with members of each post graduate year (PGY) class. Competition tasks are PGY specific: knot tying for PGY-1, basic FLS for PGY-2, hand-sewn bowel anastomosis for PGY-3, vascular anastomosis for PGY-4 and advanced laparoscopic skills for PGY-5. Competition task scores over a four-year period (2014-2017) were analyzed. In addition, a survey of teaching faculty who participated in Olympiad was conducted.

Results: 

Ten faculty members responded to the survey, for a response rate of 62.5%. Fifty percent of respondents felt that the caliber of surgical skills demonstrated at Olympiad has increased since its implementation. Ninety percent agreed that Surgical Olympiad is a good way for residents to assess their skills against their peers. Over four years there was an improvement in mean scores for knot tying (p<0.05), bowel anastomosis (p=0.08), and advanced laparoscopic skills (p<0.05).

Conclusion: 

Faculty perceive improvement in resident surgical skills since the adoption of Surgical Skills Olympiad and objective measures of resident skills suggest that the annual competition has led to improved performance. More data is needed to assess simulator use before and after Olympiad and long term surgical skill retention.

 

57.14 Multi-Lingual Pedagogy Techniques for Low Confidence First Responders: Innovative Global Trauma Defense

Posted on January 18, 2018

D. Vyas1, S. Huffman1, J. Wright1, E. Larumbe1, H. Purohit2  1Texas Tech Health Science Center School Of Medicine,Department Of Surgery,Odessa, TX, USA 2Arogyaa Healthcare Private Limited,Chennai, TAMIL-NADU, India

Introduction:

Trauma is one of the leading causes of death in the developing world and a significant source in the developed world. A major factor in morbidity and mortality in trauma patient depends on the skills and abilities of the first responders at the scene. In previous articles we had implemented the Save Trauma and Road NaviGators (STRONG) initiative, part of the Million Live Fighters (MLF) program, as an effective method to train laypersons in essential trauma skills. With this study the STRONG program will have been implemented in 6 different languages and we will demonstrate the longitudinal success of the program across multiple languages and cultural barriers.

Methods:

We recruited 135 first responders from Jaipur, India, primarily police officers, and 500 first responders from Telegana, India, a mixture of police, firefighters, nurses, and emergency medical technicians. The Jaipur group is primarily Hindi and English speaking and will be referred to as the 5th language group. The Telegana group primarily speak Telegu and English and will be referred to as the 6th language group. Each group was trained with the 10 hour Acute Trauma Training (ATT) course.

Changes in confidence and competence in 11 essential trauma skills (airway, hemorrhage, fracture, cervical spine, chest, IV lines, extrication, helmets, scene assessment, triage, and communication) were measured using voluntary pre training and post training surveys and compared using a two sample t test. These results were compared to the changes in confidence from previous studies to determine the longitudinal results of the program.

Results:

Results from the 5th and 6th Language groups demonstrated statistically significant increases in confidence levels in each of the 11 essential trauma skills (P<0.001). We found a consistent increase in confidence across all experience, education, prior trauma experience, and initial survey (p<0.01).

We observed similar unilateral increases in confidence that were consistent with previous studies in other languages. Based on these findings we can conclude that the success of the simulation based training program is highly reproducible and can be successfully translated across language and cultural barriers. With the six languages already included in the program we have a potential coverage of over one third of the global population.

Conclusion:

Participants in both language groups showed significant improvement in clinical confidence that is comparable to previous studies in other languages. Based on these results we show that the benefits to the STRONG program can be successfully transmitted across language and cultural barriers. With the current potential coverage and the rapid growth in new training locations we can rapidly increase global trauma care coverage in under served areas. In future studies we hope to include more languages such as Mandarin Chinese to increase our global coverage.

57.13 Simulation model for Laparoscopic and Robotic Foregut Surgery

Posted on January 18, 2018

F. Schlottmann1, N. S. Murty1, M. G. Patti1  1University Of North Carolina,Surgery,Chapel Hill, NC, USA

Introduction: The safe adoption of laparoscopic and robotic foregut surgery must maximize relevant training prior to transference to the clinical setting. A significant gap presently exists between box-lap and virtual-reality simulators and live surgery. Live animal and cadaver use have significant downsides. We have developed tissue-based simulator that allows for training in laparoscopic and robotic foregut operations.

Methods:  Our foregut surgery model is based on porcine tissue blocks that include lungs, heart, aorta, esophagus, diaphragm, stomach, duodenum, liver and spleen. Tissue is preserved in an alcohol based solution that retains fresh tissue characteristics for several weeks. The tissue block is mounted in a human mannequin and perfused with artificial blood. The anterior abdominal wall is constructed so as to allow for laparoscopic and robotic surgical training (Figure 1). Five expert attending foregut surgeons performed laparoscopic and robotic Heller myotomy, Nissen fundoplication and sleeve gastrectomy on the model. After completing the procedures, face validity was measured by surgeon responses to a questionnaire defining the perceived relationship to real surgery, ranging from really unrealistic to highly realistic.

Results: The initial cost of the simulator is $400. Once the initial expenses are covered (male torso mannequin and silicone based abdominal wall), the simulator cost is approximately $50 for each surgical training session (tissue block + artificial blood). The simulator was rated as highly realistic in terms of operative space, organs size and shape, and instrument usage for all three procedures in both laparoscopic and robotic surgery. In addition, all surgeons felt the model could significantly shorten the learning curve for performing these procedures.

Conclusion: The results of this study show that our model, based on animal tissue blocks, is economical, easy to use, and offers a very realistic representation of laparoscopic and robotic foregut operations, thus achieving a high level of face validity. Further validation studies are needed to assess if skills acquired by using our surgical simulator are transferable to the clinical setting

 

57.12 Immediate Visual Feedback's Impact on Skill and Confidence During Complex Tourniquet Application

Posted on January 18, 2018

J. C. Xu1, C. Kwan1, C. Pugh1  1University Of Wisconsin,School Of Medicine And Public Health,Madison, WI, USA

Introduction:

Junctional hemorrhage is a leading cause of preventable military death. Tourniquets for these difficult anatomical regions exist and are approved by the FDA to stop bleeding until arrival at a medical facility.  The purpose of this study is to compare preferences and changes in performance when using a newly designed visual bleeding feedback system(VBFS) when training novices. We hypothesize that users will indicate higher levels of confidence after training and greater improvements in training time with theleeding feedback system compared to those who train without feedback (WF).

Methods:

Medical students (N=15) and community emergency medics (N=4) with no junctional tourniquet experience were randomized in a single-blind, crossover, controlled study to start either in the VBFS group or the WF group. All subjects underwent training in the following order; instructional videos, hands on practice, three recorded skill trials in VBFS or WF, and crossover to WF or VBFS for another three trails. Participant agreement with statements asserting confidence in efficient and accurate tourniquet application and usefulness of the VBFS was assessed using a pre-and post-Likert scale with ratings from 1 to 7, with 1 being least agreement and 7 being most. Video and audio data were also collected and analyzed to assess total trail time and tourniquet application time. Group confidence scores and trial times were calculated via paired t-test. 

Results:

Participants indicated very high ratings for VBFS usefulness (6.37/7.0 +/-1.25) and recommendation to others (6.74/7.0 +/- 0.56). While there was no statistical difference in group confidence or time for the pre-and post-tests before the crossover, there was a significant reduction in application times between the 1st and 6th trial (80.5 s vs 44.4 s, p = 0.032) after crossover. It is also notable that participants in the in the VBFS spent more time than the WF groups (37.9 s vs 21.4 s, = 0.56) indicating active use of the visual feedback system. It is also noted that participants started with a fairly high confidence level in the pre-training phase compared to confidence after the 6th trial, (5.11/7.0 vs 5.37/7.0, p = 0.35). 

Conclusion: 

Trial times were increased when using the VBFS and all users rated VBFS highly. Participants were equally confident in tourniquet application after just watching a video compared to finishing the entire training with its six applications on a bleeding and non-bleeding model. Given that most participants were novices to this type of tourniquet, it is possible that they were overly confident in their original self-assessed abilities. This over confidence necessitates the need for developing effective scenario based training curricula for this deceptively straightforward life-saving task.

 

 

 

57.11 A Video-Based Coaching Intervention to Improve Surgical Skill in Fourth Year Medical Students

Posted on January 18, 2018

M. B. Alameddine1, M. Englesbe1, S. Waits1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction:  For senior medical students pursuing careers in surgery, specific technical feedback is critical for developing foundational skills in preparation for residency. This pilot study seeks to assess the feasibility of a video-based coaching intervention to improve the suturing skills of fourth year medical students. 

Methods:  Fourth-year medical students pursuing careers in surgery were randomized to intervention vs. control groups and completed two video recorded suture tasks. Students in the intervention group received a structured coaching session between consecutive suturing tasks, while students in the control group received no coaching in between suture tasks. Each coaching session consisted of a video review of the students’ first suture task with a faculty member that provided directed feedback regarding technique. Following each suturing task, students were asked to self-assess their performance and provide feedback regarding the utility of the coaching session. All videos were de-identified and graded by an independent faculty member for evaluation of suture technique. 

Results: All students who completed the coaching session (n=16) would definitely recommend the session for other students. 94% of the students strongly agreed that the exercise was a beneficial experience, and 75% strongly agreed that it improved their technical skills. Based on faculty grading, those in the control group demonstrated greater average increases in all domains of bimanual dexterity, efficiency, tissue handling, and consistency in between baseline and follow up tasks when compared to the intervention group. Conversely, on student self-assessments, those in the intervention group had greater subjective improvements in all domains of bimanual dexterity, efficiency, tissue handling, and consistency compared to the control group. Subjective, free-response comments centered on themes of becoming more aware of hand movements when viewing their suturing from a new perspective, and the usefulness of the coaching advice. 

Conclusion: This pilot study demonstrates the feasibility of a video-based coaching intervention for senior medical students. Students who participated in the coaching arm of the intervention noticed improvements in all domains of technical skill and noted that the experience was overwhelmingly positive. Although greater average improvements were seen in the control group based on faculty assessments, this result may be attributed to coached students trying new skills for the first time after being instructed on technique. In summary, video-based review shows promise as an educational tool in medical education as a means to provide specific technical feedback. 

 

57.09 In-situ OR Simulations Increases Confidence and Knowledge of Emergency Events

Posted on January 18, 2018

S. Torres Landa1, R. Caskey1, V. Zoghbi1, J. H. Atkins1, N. N. Williams1, A. D. Brooks1, K. R. Dumon1  1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction:

In-situ simulations of operating room emergencies can lead to increased patient safety and more effective teamwork amongst operating room staff. They also serve to provide training to residents in the ACGME core competencies of practice-based learning and improvement and interpersonal and communication skills. We recently revitalized our in-situ OR simulation program to include one full day per month of training and have also incorporated the TeamSTEPPS® curriculum into the training. 

Methods:

Twelve teams were formed for the simulations which include: 12 PGY-2 surgery residents, 24 PGY-3 or PGY-4 anesthesia residents and 36 perioperative registered nurses. Each team then participated in two of the following 30-minute simulations: intra-operative myocardial infarction, acute hemolytic transfusion reaction, massive post-operative hemorrhage in PACU, and tension pneumothorax in PACU. Debriefing was performed following each scenario. All simulations took place in one of the main operating rooms or PACU at our institution. Participants received introductory material about TeamSTEPPS® two weeks prior to the simulations. TeamSTEPPS® concepts were discussed during the debrief following the first simulation and then reinforced with intentional pauses during the second simulation. Participants were surveyed before and after the simulations. All survey questions were rated on a Likert scale of 1-5. Results are listed as average ± standard error of the mean. Average pre and post survey questions were evaluated using a paired t-test. 

Results:

Participants self reported increased confidence in all scenarios performed: managing intra-operative myocardial infarction (2.83±0.21 vs 4.08± 0.13, p < 0.01), acute hemolytic transfusion reaction (3.04±0.23 vs 4.04±0.13, p < 0.01), massive post-operative hemorrhage in PACU (3.5±0.15 vs 4.25±0.12, p<0.001), and tension pneumothorax in PACU (2.71±0.17 vs 4.25±0.13, p < 0.001). Participants also reported a significant increase in knowledge of TeamSTEPPS® (2.0±0.17 vs 3.88±0.17, p <0.01). Average participant score for likelihood of using TeamSTEPPS® concepts during a future, real life emergency was 4.38±0.17. Participant opinion of in-situ simulations improved following the training (4.04±0.21 vs 4.63±0.1, p < 0.02).

Conclusion:

In-situ OR simulations led to increased confidence in participants for managing the emergency situations simulated.  Incorporation of the TeamSTEPPS® curriculum into our in-situ simulation program resulted in increased knowledge of TeamSTEPPS® concepts amongst participants and led them to report a willingness to use these concepts during real life emergencies. Future evaluations at both the individual and institutional level must be done to determine the lasting impact of this training. 

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