Pamela Andreatta

Laparoscopic Skills Are Improved With LapMentor™ Training: Results of a Randomized, Double-Blinded Study

Objective:To determine if prior training on the LapMentor™ laparoscopic simulator leads to improved performance of basic laparoscopic skills in the animate operating room environment. Summary Background Data:Numerous influences have led to the development of computer-aided laparoscopic simulators: a need for greater efficiency in training, the unique and complex nature of laparoscopic surgery, and the increasing demand that surgeons demonstrate competence before proceeding to the operating room. The LapMentor™ simulator is expensive, however, and its use must be validated and justified prior to implementation into surgical training programs. Methods:Nineteen surgical interns were randomized to training on the LapMentor™ laparoscopic simulator (n = 10) or to a control group (no simulator training, n = 9). Subjects randomized to the LapMentor™ trained to expert criterion levels 2 consecutive times on 6 designated basic skills modules. All subjects then completed a series of laparoscopic exercises in a live porcine model, and performance was assessed independently by 2 blinded reviewers. Time, accuracy rates, and global assessments of performance were recorded with an interrater reliability between reviewers of 0.99. Results:LapMentor™ trained interns completed the 30° camera navigation exercise in significantly less time than control interns (166 ± 52 vs. 220 ± 39 seconds, P < 0.05); they also achieved higher accuracy rates in identifying the required objects with the laparoscope (96% ± 8% vs. 82% ± 15%, P < 0.05). Similarly, on the two-handed object transfer exercise, task completion time for LapMentor™ trained versus control interns was 130 ± 23 versus 184 ± 43 seconds (P < 0.01) with an accuracy rate of 98% ± 5% versus 80% ± 13% (P < 0.001). Additionally, LapMentor™ trained interns outperformed control subjects with regard to camera navigation skills, efficiency of motion, optimal instrument handling, perceptual ability, and performance of safe electrocautery. Conclusions:This study demonstrates that prior training on the LapMentor™ laparoscopic simulator leads to improved resident performance of basic skills in the animate operating room environment. This work marks the first prospective, randomized evaluation of the LapMentor™ simulator, and provides evidence that LapMentor™ training may lead to improved operating room performance.

Virtual Reality Triage Training Provides a Viable Solution for Disaster-preparedness

OBJECTIVES The objective of this study was to compare the relative impact of two simulation-based methods for training emergency medicine (EM) residents in disaster triage using the Simple Triage and Rapid Treatment (START) algorithm, full-immersion virtual reality (VR), and standardized patient (SP) drill. Specifically, are there differences between the triage performances and posttest results of the two groups, and do both methods differentiate between learners of variable experience levels? METHODS Fifteen Postgraduate Year 1 (PGY1) to PGY4 EM residents were randomly assigned to two groups: VR or SP. In the VR group, the learners were effectively surrounded by a virtual mass disaster environment projected on four walls, ceiling, and floor and performed triage by interacting with virtual patients in avatar form. The second group performed likewise in a live disaster drill using SP victims. Setting and patient presentations were identical between the two modalities. Resident performance of triage during the drills and knowledge of the START triage algorithm pre/post drill completion were assessed. Analyses included descriptive statistics and measures of association (effect size). RESULTS The mean pretest scores were similar between the SP and VR groups. There were no significant differences between the triage performances of the VR and SP groups, but the data showed an effect in favor of the SP group performance on the posttest. CONCLUSIONS Virtual reality can provide a feasible alternative for training EM personnel in mass disaster triage, comparing favorably to SP drills. Virtual reality provides flexible, consistent, on-demand training options, using a stable, repeatable platform essential for the development of assessment protocols and performance standards.

Using cell phones to collect postpartum hemorrhage outcome data in rural Ghana

To evaluate the use of cell phones by professional and traditional birth attendants in rural Africa for reporting postpartum hemorrhage (PPH) data.

Low-hanging fruit: A clementine as a simulation model for advanced laparoscopy

Introduction Low-cost, high-fidelity models for training in advanced laparoscopic surgery techniques are not currently available. The objective of this study was to evaluate a model and assessment protocol for developing associated fine, precise laparoscopic dissection skills with accompanying surgical decision making. Methods Novice to expert laparoscopists (n = 41) were asked to remove the peel of a clementine in as few pieces as possible, separate and remove all albedo from and between all fruit segments, and return the clementine to as close to its natural state as possible with completely closed skin (sutured). Clinical decision making included deciding when unacceptable segment damage would result by removing difficult-to-extract albedo, analogous to treating lesions or metastases through other methods, rather than risking damage to vital anatomic structures. Faculty assessed deidentified video-recorded performances. Data analyses included analysis of variance with Bonferroni post hoc. Results A single-performance construct (operative ability) with 2 scoring dimensions (surgical skills and clinical judgment) was confirmed through factor analysis. There were significant performance differences between all experience levels (F2,41 = 59.175, P < 0.000). There were no statistical time differences between the groups. Conclusions Validation of this low-cost, easily facilitated model for developing advanced laparoscopic surgical skills may support the preparation of residents and fellows and provide a platform for skill acquisition, assessment, and basic critical thinking for performing laparoscopic tasks.

Simulation-based training improves applied clinical placement of ultrasound-guided PICCs

PurposeSkilled placement of peripherally inserted central catheters (PICC) has a profound impact on patient well-being and costs of care. The use of ultrasound-guided methods and prescribed training for cannulation skills are evidence-based practice recommendations. The purpose of this study was to compare two methods of PICC instruction on the acquisition of applied skills.MethodsResidents were randomly assigned to one of two groups (N = 16/16) of this blind-rater study and were trained to perform ultrasound-guided PICC cannulation using either simulation or apprenticeship methods. All residents were assessed placing a PICC in applied clinical patient care.ResultsResidents who completed simulation training had significantly better transfer of skills to applied clinical practice than residents who received apprenticeship training, having better performance ratings on eight of nine procedure-specific task measures (p < 0.05) and higher success rates in endpoint PICC placement.ConclusionsThese results support the use of prescribed simulation-based training for the acquisition of requisite skills associated with PICC placement and expand on similar studies that suggest the advantages of simulation-based training for central line placement. Additionally, the data suggest that training using a single simulation model may support the acquisition of both central venous catheterization and PICC skills.

Conceptualising and classifying validity evidence for simulation.

Context  The term ‘validity’ is used pervasively in medical education, especially as it relates to curriculum, assessment, measurement and instrumentation. Exactly what is meant by the term ‘validity’ in the medical education literature is not always clearly defined.

Simulation and team training

The use of simulation-based methods for clinical and team training provides an opportunity for health care professionals to develop and maintain the skills required to effectively manage patient care. This is especially true for those rare events when emergency interventions require urgent, accurate, and cohesive team functioning. We present a framework for considering simulation-based training, examine contextual factors and the outcomes of research conducted to date in this area, and provide suggestions for selecting simulation-based approaches for developing obstetrics and gynecology teams in multiple contexts.

Cell Phones to Collect Pregnancy Data From Remote Areas in Liberia

Purpose: To report findings on knowledge and skill acquisition following a 3-day training session in the use of short message service (SMS) texting with non- and low-literacy traditional midwives. Design: A pre- and post-test study design was used to assess knowledge and skill acquisition with 99 traditional midwives on the use of SMS texting for real-time, remote data collection in rural Liberia, West Africa. Methods: Paired sample t-tests were conducted to establish if overall mean scores varied significantly from pre-test to immediate post-test. Analysis of variance was used to compare means across groups. The nonparametric McNemars test was used to determine significant differences between the pre-test and post-test values of each individual step involved in SMS texting. Pearsons chi-square test of independence was used to examine the association between ownership of cell phones within a family and achievement of the seven tasks. Findings: The mean increase in cell phone knowledge scores was 3.67, with a 95% confidence interval ranging from 3.39 to 3.95. Participants with a cell phone in the family did significantly better on three of the seven tasks in the pre-test: “turns cell on without help” (χ2(1) = 9.15, p= .003); “identifies cell phone coverage” (χ2(1) = 5.37, p= .024); and “identifies cell phone is charged” (χ2(1) = 4.40, p= .042). Conclusions: A 3-day cell phone training session with low- and nonliterate traditional midwives in rural Liberia improved their ability to use mobile technology for SMS texting. Clinical Relevance: Mobile technology can improve data collection accessibility and be used for numerous health care and public health issues. Cell phone accessibility holds great promise for collecting health data in low-resource areas of the world. Journal of Nursing Scholarship, 2012; 00:0, 1–8.

LapMentor metrics possess limited construct validity.

Background: Many surgical training programs are introducing virtual-reality laparoscopic simulators into their curriculum. If a surgical simulator will be used to determine when a trainee has reached an “expert” level of performance, its evaluation metrics must accurately reflect varying levels of skill. The ability of a metric to differentiate novice from expert performance is referred to as construct validity. The present study was undertaken to determine whether the LapMentors metrics demonstrate construct validity. Methods: Medical students, residents and faculty laparoscopic surgeons (n = 5–14 per group) performed 5 consecutive repetitions of 6 laparoscopic skills tasks: 30° Camera Manipulation, Eye-Hand Coordination, Clipping/Grasping, Cutting, Electrocautery, and Translocation of Objects. The LapMentor measured performance in 4 to 12 parameters per task. Mean performance for each parameter was compared between subject groups for the first and fifth repetitions. Pairwise comparisons among the 3 groups were made by post hoc t-tests with Bonferroni technique. Significance was set at P < 0.05. Results: Of the 6 tasks evaluated, only the Eye-Hand Coordination task (3/12 parameters) and the Clipping and Grasping (1/7 parameters) had expert-level discrimination when performance was compared after completion of 1 repetition. Comparison of the fifth repetition performance (representing the plateau of the learning curves), demonstrated that the parameters Time and Score had expert level discrimination on the Eye-Hand Coordination task, and Time on the Cutting task. The remaining LapMentor tasks evaluated did not exhibit the ability to differentiate level of expertise based on the built-in metrics on either repetition 1 or 5. Conclusions: The majority of the LapMentor tasks’ metrics were unable to differentiate between laparoscopic experts and less skilled subjects. Therefore, performance on those tasks may not accurately reflect a subjects true level of ability. Feedback to the manufacturer about these findings may encourage the development of evaluation parameters with greater sensitivity.

Interdisciplinary team training identifies discrepancies in institutional policies and practices

The objective of this study was to evaluate the impact of an interdisciplinary team-training program in obstetric emergencies on identifying unsupportive institutional policies and systems-based practices. We implemented a qualitative study design with a purposive sample of interdisciplinary physicians, nurses, and ancillary allied health professionals from 4 specialties (n = 79) to conduct a 6-month, weekly simulation-based intervention for managing obstetric emergencies. Debriefing focused on identifying discrepancies between clinical practice and institutional policies. Our data yielded 5 categories of discrepancies between institutional or departmental policy and actual clinical practice. Specific institutional policies and system-based practices were recommended to health system administration for reevaluation. Simulation-based interdisciplinary team training can inform system-wide quality improvement objectives that could lead to increased patient safety.