Philip H. Pucher

Clinical outcome following Doppler‐guided haemorrhoidal artery ligation: a systematic review

Doppler‐guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy.

A randomized controlled study to evaluate the role of video-based coaching in training laparoscopic skills.

OBJECTIVE This study evaluates whether video-based coaching can enhance laparoscopic surgical skills performance. BACKGROUND Many professions utilize coaching to improve performance. The sports industry employs video analysis to maximize improvement from every performance. METHODS Laparoscopic novices were baseline tested and then trained on a validated virtual reality (VR) laparoscopic cholecystectomy (LC) curriculum. After competence, subjects were randomized on a 1:1 ratio and each performed 5 VRLCs. After each LC, intervention group subjects received video-based coaching by a surgeon, utilizing an adaptation of the GROW (Goals, Reality, Options, Wrap-up) coaching model. Control subjects viewed online surgical lectures. All subjects then performed 2 porcine LCs. Performance was assessed by blinded video review using validated global rating scales. RESULTS Twenty subjects were recruited. No significant differences were observed between groups in baseline performance and in VRLC1. For each subsequent repetition, intervention subjects significantly outperformed controls on all global rating scales. Interventions outperformed controls in porcine LC1 [Global Operative Assessment of Laparoscopic Skills: (20.5 vs 15.5; P = 0.011), Objective Structured Assessment of Technical Skills: (21.5vs 14.5; P = 0.001), and Operative Performance Rating System: (26 vs 19.5; P = 0.001)] and porcine LC2 [Global Operative Assessment of Laparoscopic Skills: (28 vs 17.5; P = 0.005), Objective Structured Assessment of Technical Skills: (30 vs 16.5; P < 0.001), and Operative Performance Rating System: (36 vs 21; P = 0.004)]. Intervention subjects took significantly longer than controls in porcine LC1 (2920 vs 2004 seconds; P = 0.009) and LC2 (2297 vs 1683; P = 0.003). CONCLUSIONS Despite equivalent exposure to practical laparoscopic skills training, video-based coaching enhanced the quality of laparoscopic surgical performance on both VR and porcine LCs, although at the expense of increased time. Video-based coaching is a feasible method of maximizing performance enhancement from every clinical exposure.

Validation of the simulated ward environment for assessment of ward-based surgical care.

Objective:To assess the feasibility of developing a simulated ward environment in which to assess the ward-based care of surgical patients by clinicians of varying levels of experience (construct validation). Background:Increasing evidence points to the importance of the postoperative or ward-based phase of surgical care in determining patient outcomes. Ward-based care is determined by the clinician ward round, with the simulated ward environment potentially providing a safe environment for training and assessment. Methods:A high-fidelity surgical ward environment was developed. Junior and senior trainees conducted ward rounds of 3 standardized surgical patients and were assessed using a checklist of assessment and management care processes, modified NOTECHS score, and fidelity questionnaire. Results:Nine senior and 9 junior trainees were observed. There was no significant difference in time taken to conduct the round (37.6 ± 2.7 vs 32.6 ± 1.9 minutes, P = 0.16). Senior trainees performed significantly more assessment processes (73% ± 2.8% vs 63% ± 2.5%, P = 0.016) and completed more management tasks (73% ± 4.5% vs 59.4% ± 5%, P = 0.058). Fifteen adverse events were committed by junior trainees versus 8 by seniors (P < 0.001). Seniors scored higher on nontechnical ability (NOTECHS score 21.8 ± 0.61 vs 18.1 ± 1.12, P = 0.017). All of subjects felt the ward, patients, and scenarios were realistic. Conclusions:A high-fidelity, immersive, construct-valid ward simulator has been developed in which to observe and assess ward-based processes of surgical care.

Surgical ward round quality and impact on variable patient outcomes.

Objective:To investigate the relationship between variability in surgical ward round (WR) quality and clinical outcomes. Background:Evidence increasingly suggests that ward-based care plays a key role in surgical outcomes. The WR is the focal point of surgical inpatient care. Assimilating various sources of clinical information is necessary for thorough patient assessment during the WR; whether this relates to outcomes has not previously been examined. Methods:WRs were observed for patients on a surgical high-dependency unit in a tertiary academic surgical unit. All sources of clinical information (SCI) were considered. Thoroughness of assessment, defined as the percentage of SCI assessed by the clinician, was recorded as a marker of WR quality. Complications were recorded from patient records; preventability was based on Agency for Healthcare and Research Quality guidelines. The relationship between WR quality and incidence of preventable complications was analyzed. Results:Sixty-nine WRs were observed over 37 days for 50 patients receiving care in the high-dependency unit. Observed morbidity rate was 60% (30/50). Seventy-four percent of all complications (35/46) occurred on the high-dependency unit. There was significant variability in WR quality: clinicians assessed 9% to 91% (mean = 55% ± 17%) of SCI (analysis of variance P = 0.025). Low-quality (% SCI assessed less than the mean) WRs resulted in a greater incidence of patients experiencing preventable complications [83% (10/12) vs 39% (7/18)] (P = 0.034), odds ratio = 6.43 (95% confidence interval = 1.05–39.3). Forty-one percent of complications (19/46) could have been diagnosed earlier or possibly prevented. Conclusions:Patient assessment during WRs is variable. Less thorough WRs result in delayed diagnoses and preventable complications, and they negatively affect outcomes. Focusing on WR quality and training may improve patient care.

Eye tracking for skills assessment and training: a systematic review

BACKGROUND The development of quantitative objective tools is critical to the assessment of surgeon skill. Eye tracking is a novel tool, which has been proposed may provide suitable metrics for this task. The aim of this study was to review current evidence for the use of eye tracking in training and assessment. METHODS A systematic literature review was conducted in line with PRISMA guidelines. A search of EMBASE, OVID MEDLINE, Maternity and Infant Care, PsycINFO, and Transport databases was conducted, till March 2013. Studies describing the use of eye tracking in the execution, training or assessment of a task, or for skill acquisition were included in the review. RESULTS Initial search results returned 12,051 results. Twenty-four studies were included in the final qualitative synthesis. Sixteen studies were based on eye tracking in assessment and eight studies were on eye tacking in training. These demonstrated feasibility and validity in the use of eye tracking metrics and gaze tracking to differentiate between subjects of varying skill levels. Several training methods using gaze training and pattern recognition were also described. CONCLUSIONS Current literature demonstrates the ability of eye tracking to provide reliable quantitative data as an objective assessment tool, with potential applications to surgical training to improve performance. Eye tracking remains a promising area of research with the possibility of future implementation into surgical skill assessment.

Meta‐analysis of the effect of postoperative in‐hospital morbidity on long‐term patient survival

Major surgery is associated with high rates of postoperative complications, many of which are deemed preventable. It has been suggested that these complications not only present a risk to patients in the short term, but may also reduce long‐term survival. The aim of this review was to examine the effects of postoperative complications on long‐term survival.

Ward simulation to improve surgical ward round performance: a randomized controlled trial of a simulation-based curriculum.

Objective:This study aimed to investigate the effects of a simulation-based curriculum for ward-based care on ward round (WR) performance. Background:Variability in surgical outcomes does not relate to surgical skill alone. Prevention, diagnosis, and treatment of peri- and postoperative morbidity are dependent on provision of high-quality ward-based care. The focal point of this is the surgical WR. Although WR conduct is learned primarily through experience, a simulated environment and validated assessment tools may enable measurement and enhancement of WR quality. Methods:Junior surgical residents were randomized either to a half-day educational intervention with lectures, structured feedback, and debriefing, or to standard practice (control). All conducted a standardized, validated, simulated WR of 3 patients. Surgical Ward Care Assessment Tool and W-NOTECHS rating scales were used for technical and nontechnical skills assessment, respectively, and compared between groups. Subjects completed pre- and posttest confidence questionnaires and feedback forms. Results:Twenty-nine trainees were randomized to intervention (n = 14) or control (n = 15). Baseline confidence and demographics were equal between groups. Intervention group demonstrated better patient assessment: 63.5 ± 8.1% (control) versus 79.8 ± 11.9% (P = 0.002), management 56.0% ± 19.7% versus 72.2 ± 10.3% (P = 0.014), and nontechnical skills: W-NOTECHS 17.75 ± 2.06 versus 23.33 ± 1.21 (P < 0.001). Hundred percent of subjects felt that the curriculum improved their practice. Conclusions:Conducting WRs is a crucial skill but not currently subject to formal training. Implementation of a comprehensive curriculum for surgical WRs led to significant improvement in quality of patient assessment, management, and nontechnical skills. Improved WR performance may lead to earlier identification and amelioration of complications and improve patient outcomes.

Virtual-world hospital simulation for real-world disaster response: design and validation of a virtual reality simulator for mass casualty incident management

BACKGROUND Mass casualty incidents are unfortunately becoming more common. The coordination of mass casualty incident response is highly complex. Currently available options for training, however, are limited by either lack of realism or prohibitive expense and by a lack of assessment tools. Virtual worlds represent a potentially cost-effective, immersive, and easily accessible platform for training and assessment. The aim of this study was to assess feasibility of a novel virtual-worlds–based system for assessment and training in major incident response. METHODS Clinical areas were modeled within a virtual, online hospital. A major incident, incorporating virtual casualties, allowed multiple clinicians to simultaneously respond with appropriate in-world management and transfer plans within limits of the hospital’s available resources. Errors, delays, and completed actions were recorded, as well as Trauma-NOnTECHnical Skills (T-NOTECHS) score. Performance was compared between novice and expert clinician groups. RESULTS Twenty-one subjects participated in three simulations: pilot (n = 7), novice (n = 8), and expert groups (n = 6). The novices committed more critical events than the experts, 11 versus 3, p = 0.006; took longer to treat patients, 560 (299) seconds versus 339 (321) seconds, p = 0.026; and achieved poorer T-NOTECHS scores, 14 (2) versus 21.5 (3.7), p = 0.003, and technical skill, 2.29 (0.34) versus 3.96 (0.69), p = 0.001. One hundred percent of the subjects thought that the simulation was realistic and superior to existing training options. CONCLUSION A virtual-worlds–based model for the training and assessment of major incident response has been designed and validated. The advantages of customizability, reproducibility, and recordability combined with the low cost of implementation suggest that this potentially represents a powerful adjunct to existing training methods and may be applicable to further areas of surgery as well.

Randomized clinical trial of the impact of surgical ward-care checklists on postoperative care in a simulated environment.

Complications are a common and accepted risk of surgery. Failure to optimize the management of patients who suffer postoperative morbidity may result in poorer surgical outcomes. This study aimed to evaluate a checklist‐based tool to improve and standardize care of postoperative complications.

Simulation for ward processes of surgical care

The role of simulation in surgical education, initially confined to technical skills and procedural tasks, increasingly includes training nontechnical skills including communication, crisis management, and teamwork. Research suggests that many preventable adverse events can be attributed to nontechnical error occurring within a ward context. Ward rounds represent the primary point of interaction between patient and physician but take place without formalized training or assessment. The simulated ward should provide an environment in which processes of perioperative care can be performed safely and realistically, allowing multidisciplinary assessment and training of full ward rounds. We review existing literature and describe our experience in setting up our ward simulator. We examine the facilities, equipment, cost, and personnel required for establishing a surgical ward simulator and consider the scenario development, assessment, and feedback tools necessary to integrate it into a surgical curriculum.