Chan W. Park

Interprofessional Simulation: Prioritizing Interprofessional Competencies to Improve Patient Outcomes.

Nursing professional development (NPD) specialists are increasingly being tasked to develop educational curricula that are associated with measurable quality improvements and/or clinical outcomes. In order to address these needs, it is imperative that NPD specialists offer training programs that are evidence based, data driven, andassociatedwith aparticular quality improvement or patient care goal while maintaining relevance for the learners. At first glance, this taskmay appear daunting, however, it is certainly not insurmountable. One solution we recommend involves prioritization of the learning objectives, while using the interprofessional team (IPT) platform to provide the realism and clinical relevance. Almost all of what we do as clinicians involves interprofessionalism. Although our roles and responsibilities may differ, aswe focus onour patients and the optimal care to be delivered, it is not difficult to see how interprofessional (IP) training and team environment brings together the competency domains (Values/Ethics, Roles/Responsibilities, IP Communication, and Teams and Teamwork) described in the 2011 Core Competencies for Interprofessional Collaborative Practice that all disciplines strive to achieve. So, why not develop our training curriculum involving IPT setting? Our previous column introduced these interprofessional collaborative competency domains, and challenged NPD specialists to think about ways to incorporate these domains into their existing interprofessional education (IPE). One strategy to consider involves utilizing the framework set forth by the IOM and the five competencies for IPT. This IOM framework below highlights individual components and how they can be developed to enhance the quality of the IPT training, which we believe will ultimately improve patient-centered care (IOM, 2003) (see Figure 1). Here are two practical suggestions to consider for all of our outstandingNPD specialists. For the vastmajority of the NPD specialists, the objective of training involves an aspect of applying the current evidence-based practice to improve the quality of patient care. We encourage strategies that allow for data acquisition that is simple but relevant, to support the notion that it has improved the overall IPT training experience. Using code response emergency team training as an example, onemight track the rate and depth of the CPR being

Single-incision laparoscopic right colectomy: an efficient technique.

Purpose: Laparoscopic right colectomy has an established patient benefit. We sought to demonstrate that a single-incision approach to laparoscopic right colectomy is safe, reproducible, and efficient. Methods: Photographs were acquired from cases to depict a step-by-step approach. We collected operative, pathologic, and postoperative outcomes from 8 patients who underwent a single-incision laparoscopic right colectomy. Results: There were no intraoperative complications nor deaths and 3 complications postoperatively. The average return of bowel function and length of stay was 3 and 5 days, respectively. Pathologic assessment revealed negative margins and an average of 17 lymph nodes harvested from the specimens. Conclusions: Single-incision laparoscopic right colectomy is an evolving technique and likely to supplant conventional laparoscopic colectomy because of its equivalent and reproducible outcomes and the ease of the procedure. We depict our preferred method and review the current literature of single-incision right colectomy.

Bipolar Electrosurgical Devices

From the early days of direct cautery and monopolar radiofrequency (RF) instrumentation, bipolar electrosurgical devices have evolved and enabled remarkable surgical outcomes in today’s technologically advanced operating room. Inherent in the bipolar design is an increased degree of electrosurgical safety, and through ongoing innovation, these instruments continue to enhance surgical efficacy and efficiency. Currently, there exist a variety of electrosurgical devices, each with its own unique characteristics and features, but comparative studies that allow meaningful analyses and evaluation are somewhat lacking. Further study and future research are necessary and mandatory in order to keep pace with rapid advancements.

Interprofessional Simulation: Creative Ways to Integrate Education and Goal Setting in the Practice Environment

In our previous column, we introduced the concept of viewing interprofessional (IP) simulation training from the patient’s point of view. We discussed how this framework helps promote patient centeredness for both educators and learners. In this column, we will explore another creative way to integrate interprofessional education (IPE) and IP goal setting in our simulation arena, using the framework for Stroke Emergency Response Team training. Manyof usworkwithpatientswith strokes andare familiar with the American Heart Association Get With the Guidelines for Stroke. Despite our familiarity with the stroke lexicon, ‘‘National Institutes of Health (NIH) Stroke Scale,’’ ‘‘Door to Needle Time,’’ and ‘‘Time is Brain’’ (Jauch et al., 2013), some providers and facilities fail to realize the importance of activating the full stroke emergency response to see how personnel, process, and systems issues impact the ability to provide optimal patient care. Given no two hospital systems are exactly alike, it is advisable for the nursing professional development (NPD) practitioner to consider systems integration and process flow testing of any ‘‘best practice’’ measures at the local facility before adopting any protocols. One of the main goals of stroke treatment is to optimize all aspects of the detection, diagnosis, and management process. For example, if the patient with stroke symptoms is a thrombolytic candidate, the time measured from presentation to thrombolytic administration (Door to Needle Time) should be less than 60 minutes. This is not to be confused with the 4.5 hours, which is the recent expanded cutoff time from the time of symptom onset to when a thrombolytic can be administered under the American Heart Association guidelines (Jauch et al., 2013). Yet, how many of us who work in a designated ‘‘stroke center’’ regularly rehearse our stroke activation across the continuum of care to include the entire IP team of nurses, physicians, patient transporters, radiologists, computed tomography technicians, pharmacists, and qualitymanagement personnel? Some facilities make the assumption that, once a standard operating procedure has been reviewed and signed off by the subject matter experts, everything will occur as written. Yet, how many of us can attest to the fact that, in the real world, this is not the case? If nothing else, it is a vulnerability and could be a possible disaster waiting to happen. Studies have shown that variance in the quality of care exists depending on factors such as day of the week, weekends, holidays, and even the time of the shift (McKinney, Deng, Kasner, Kostis, & Myocardial Infarction Data Acquisition System [MIDAS 15] Study Group, 2011). Knowing this, how confident are we that all of our staff can immediately recognize the signs and symptoms of a stroke, swiftly activate the emergency response system, and subsequently implement definitive care for the patient with stroke based on national metrics? Is it fair to say that there are many staff who work in our medical facility who have not yet experienced a systems-wide activation of a stroke code and do not know the challenges involved? For those who can say ‘‘yes’’ to the preceding question, Chan W. Park, MD, FAAEM, is Director of Simulation Education and Co-Director, Interprofessional Advanced Fellowship in Clinical Simulation, U.S. Department of Veterans Affairs, Durham VA Medical Center, North Carolina. Mary Edel Holtschneider, MPA, BSN, RN-BC, NREMT-P, CPLP, is Simulation Education Coordinator and Co-Director, Interprofessional Advanced Fellowship inClinical Simulation,U.S. Department of Veterans Affairs, Durham VA Medical Center, North Carolina.

Future of Interprofessional Simulation Education in the Practice Setting.

In our past columns on interprofessional education (IPE) and simulation, we explored creative ways to link interprofessional (IP) competencies to patient-centered care. We offered several ideas on how to achieve this by changing the point of reference of the debrief from that of the instructor and learners’ objectives to that of the patient’sobjectives.Weconclude this IPE serieswitha ‘‘simulated question and answer’’ session that addresses several questions from our readers and offers parting thoughts from the authors regarding the futureof simulation for IPE and training. CWP: Okay,Mary, here’s a question fromBob in Florida. ‘‘I’m having trouble getting physicians to participate in the IPE sessions at my hospital. Is this normal?What suggestions would you have for someone in my similar circumstance?’’ MEH: Chan, that is a good question. I think many of us have experienced challenges with fully engaging our physician colleagues in IP simulation education. I have observed that many physicians are interested in participating in simulations, though not necessarily with other professions. Often, this has to do with the technical skills that they need to practice andmaster, which I can definitely appreciate. For example, they need to be proficient at airway management, central line insertion, and other invasive procedures. Though there are certainly components of working with other team members on these techniques, physicians need to be able to focus on their responsibilities and ensure their own proficiency. As nursing professional development (NPD) practitioners, we need to support this aspect of simulation and reframe the question from ‘‘how do I get physicians to participate’’ to ‘‘how can I make IPE relevant to all involved?’’ Increasing the relevance of IP simulation scenarios takes a good bit of work, experimentation, and willingness to collaborate with other professions to maximize the educational experience. It is also important to recognize that, although NPD practitioners can be excellent simulation facilitators, having other professions help with the teaching and debriefing can go a long way in gaining engagement from everyone on the team, regardless of profession. Partneringwith other professions for these educational activities demonstrates positive IP role modeling and can help others see its benefits. MEH: Chan, as you view this dilemma from a physician perspective, what other thoughts do you have on how to increase physician engagement and participation? What practical suggestions do you have for NPD practitioners to add relevance to their simulation scenarios so that physicians find maximum benefit from participating? CWP: Mary, I think you brought up several excellent points. First and foremost, when an IPE is being considered, it is essential for NPD practitioners to consider which professions need to be present and how eachmember will benefit from the participation. When dealing with the physician community, it is important to point out the increasing emphasis on effective communication, team leadership, and error reduction. Simulated code response training lends itself well to developing key elements of effective communication and team leadership. Since many physicians are required to maintain competence in key procedures, an interprofessional team (IPT) training session can be developed around potential complications and/or errors that occur during the handoff upon completion of the procedure. This would allow the physicians to gain from their psychomotor training, and to learn how to anticipate and address potential complications that can occur. It’s amazing how effective communication can be when everyone is engaged and in complete agreement with the eventual goal of the simulation training. Chan W. Park, MD, FAAEM, is Director of Simulation Education and Co-Director, Interprofessional Advanced Fellowship in Clinical Simulation, U.S. Department of Veterans Affairs, Durham VA Medical Center, North Carolina. Mary Edel Holtschneider, MPA, BSN, RN-BC, NREMT-P, CPLP, is Simulation Education Coordinator and Co-Director, Interprofessional Advanced Fellowship in Clinical Simulation,U.S.Department of Veterans Affairs, Durham VA Medical Center, North Carolina.

Basic Setup, Principles, and Troubleshooting in Robotic Surgery

The robotic-assisted surgery (RAS) platform is a highly sophisticated and complex surgical tool that requires formal training for initial credentialing and the progressive accumulation of experience for surgical proficiency. This chapter presents a general overview of the RAS platform and its many hardware components with an emphasis on maximizing pre-procedural planning and equipment setup. Principles for safe and efficient use of this advanced surgical technology are discussed, and key differences between RAS and laparoscopic surgery are also explored. Although a comprehensive explanation of all of the complexities of RAS is beyond the scope of this text, some troubleshooting tips and strategies for addressing commonly encountered surgical challenges are provided.

Laparoscopic repair of a large pericardial hernia

Pericardial hernias (PH) are rare entities, and surgical experience in dealing with these defects is limited. PH develop through either a congenital or acquired defect in the central tendon of the diaphragm, and in adults, PH are usually associated with high-energy traumatic rupture or develop as an iatrogenic consequence of surgical interventions, such as pericardial window procedures, cardiac surgery, etc. [1–4]. Although the role of laparoscopy in the diagnosis and management of diaphragmatic and paraesophageal hernias is well known, experience with a minimally invasive surgical approach to the repair of PH is not well established.

25. Laparoscopic Palliation for Pancreatic Cancer

The role of laparoscopy in the management of pancreatic cancer continues to evolve. With advancements in minimally invasive surgery (MIS) techniques, laparoscopy has become an accepted approach to initial surgical inspection of the peritoneal cavity and can play a key role in determining resectability of pancreatic cancer. Contemporary surgical management of pancreatic cancer now incorporates innovative MIS techniques beyond just the “first-look,” and even in cases of unresectable cancer, laparoscopy offers the patient viable therapeutic options to palliate underlying disease symptoms and maintain the quality of life while significantly minimizing associated surgical morbidity. These patient derived benefits of an MIS approach can be significant since nearly 80% of pancreatic cancer patients are deemed unresectable and require palliative surgical options. This chapter outlines techniques for laparoscopic palliation of pancreatic cancer and discusses key surgical considerations for patient management.

7. Single-Site Access Surgery

Laparoendoscopic single-site (LESS) surgery has emerged as a method to employ existing laparoscopic techniques via a single incision. The technique has gained tremendous momentum, and its feasibility has been demonstrated throughout multiple surgical disciplines. LESS may offer improved cosmesis and may have other potential advantages over conventional multiport laparoscopy. Clinical trials, some already underway, will determine if these advantages indeed accrue and how significant they are. This chapter describes basic principles and gives technical tips for success and the means by which the problems inherent in the modality may be minimized.