Jay N. Nathwani

Relationship Between Technical Errors and Decision-Making Skills in the Junior Resident

OBJECTIVE The purpose of this study is to coevaluate resident technical errors and decision-making capabilities during placement of a subclavian central venous catheter (CVC). We hypothesize that there would be significant correlations between scenario-based decision-making skills and technical proficiency in central line insertion. We also predict residents would face problems in anticipating common difficulties and generating solutions associated with line placement. DESIGN Participants were asked to insert a subclavian central line on a simulator. After completion, residents were presented with a real-life patient photograph depicting CVC placement and asked to anticipate difficulties and generate solutions. Error rates were analyzed using chi-square tests and a 5% expected error rate. Correlations were sought by comparing technical errors and scenario-based decision-making skills. SETTING This study was performed at 7 tertiary care centers. PARTICIPANTS Study participants (N = 46) largely consisted of first-year research residents who could be followed longitudinally. Second-year research and clinical residents were not excluded. RESULTS In total, 6 checklist errors were committed more often than anticipated. Residents committed an average of 1.9 errors, significantly more than the 1 error, at most, per person expected (t(44) = 3.82, p < 0.001). The most common error was performance of the procedure steps in the wrong order (28.5%, p < 0.001). Some of the residents (24%) had no errors, 30% committed 1 error, and 46 % committed more than 1 error. The number of technical errors committed negatively correlated with the total number of commonly identified difficulties and generated solutions (r (33) = -0.429, p = 0.021, r (33) = -0.383, p = 0.044, respectively). CONCLUSIONS Almost half of the surgical residents committed multiple errors while performing subclavian CVC placement. The correlation between technical errors and decision-making skills suggests a critical need to train residents in both technique and error management.

Can a virtual reality assessment of fine motor skill predict successful central line insertion

BACKGROUND Due to the increased use of peripherally inserted central catheter lines, central lines are not performed as frequently. The aim of this study is to evaluate whether a virtual reality (VR)-based assessment of fine motor skills can be used as a valid and objective assessment of central line skills. METHODS Surgical residents (N = 43) from 7 general surgery programs performed a subclavian central line in a simulated setting. Then, they participated in a force discrimination task in a VR environment. Hand movements from the subclavian central line simulation were tracked by electromagnetic sensors. Gross movements as monitored by the electromagnetic sensors were compared with the fine motor metrics calculated from the force discrimination tasks in the VR environment. RESULTS Long periods of inactivity (idle time) during needle insertion and lack of smooth movements, as detected by the electromagnetic sensors, showed a significant correlation with poor force discrimination in the VR environment. Also, long periods of needle insertion time correlated to the poor performance in force discrimination in the VR environment. CONCLUSIONS This study shows that force discrimination in a defined VR environment correlates to needle insertion time, idle time, and hand smoothness when performing subclavian central line placement. Fine motor force discrimination may serve as a valid and objective assessment of the skills required for successful needle insertion when placing central lines.

Hand smoothness in laparoscopic surgery correlates to psychomotor skills in virtual reality

The main purpose of this study is to find possible relationships between the smoothness of hand function during laparoscopic ventral hernia (LVH) repair and psychomotor skills in a defined virtual reality (VR) environment. Thirty four surgical residents N = 34 performed two scenarios. First, participants were asked to perform a simulated LVH repair during which their hand movement was tracked using electromagnetic sensors. Subsequently, the smoothness of hand function was calculated for each participants dominant and non-dominate hand. Then participants performed two modules in a defined VR environment, which assessed their force matching and target tracking capabilities. More smooth hand function during the LVH repair correlated positively with higher performance in VR modules. Also, translational smoothness of dominant hand is found as the most informative smoothness metric in the LVH repair scenario. Therefore, defined force matching and target tracking assessments in VR can potentially be used as an indirect assessment of fine motor skills in the LVH repair.

Shortcut assessment: Can residents’ operative performance be determined in the first five minutes of an operative task?

Background: The aim was to validate the potential use of a single, early procedure, operative task as a predictive metric for overall performance. The authors hypothesized that a shortcut psychomotor assessment would be as informative as a total procedural psychomotor assessment when evaluating laparoscopic ventral hernia repair performance on a simulator. Methods: Using electromagnetic sensors, hand motion data were collected from 38 surgery residents during a simulated laparoscopic ventral hernia repair procedure. Three time‐based phases of the procedure were defined: Early Phase (start time through completion of first anchoring suture), Mid Phase (start time through completion of second anchoring suture), and Total Operative Time. Correlations were calculated comparing time and motion metrics for each phase with the final laparoscopic ventral hernia repair score. Results: Analyses revealed that execution time and motion, for the first anchoring suture, predicted procedural outcomes. Greater execution times and path lengths correlated to lesser laparoscopic ventral hernia repair scores (r=‐0.56, P=.0008 and r=‐0.51, P=.0025, respectively). Greater bimanual dexterity measures correlated to Greater LVH repair scores (r=+0.47, P=.0058). Conclusions: This study provides validity evidence for use of a single, early operative task as a shortcut assessment to predict resident performance during a simulated laparoscopic ventral hernia repair procedure. With the continued development and decreasing costs of motion technology, faculty should be well‐versed in the use of motion metrics for performance measurements. The results strongly support the use of dexterity and economy of motion (path length+execution time) metrics as early predictors of operative performance.