The emergency surgical airway: Bridging the gap from quality outcome to performance improvement through a novel simulation based curriculum

doi:10.1016/j.amjsurg.2018.09.026

The American Journal of Surgery

Volume 217, Issue 3, March 2019, Pages 562-565

https://doi.org/10.1016/j.amjsurg.2018.09.026 Get rights and content

Highlights

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Patient safety is a significant driving force for simulation.
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Gaps in training for low frequency, high risk scenarios can be addressed.
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Design and implementation of an advanced surgical airway curriculum is feasible.
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Measuring the effectiveness of this curriculum on clinical practice remains elusive.

Abstract

Background

Emergency surgical airway is a low frequency, high risk clinical scenario. Implementing a simulation-based curriculum may bridge the gap in surgical training and address quality assurance/performance improvement (QAPI) needs.

Methods

We designed and implemented an Advanced Surgical Airway Curriculum (ASAC) modeled after proficiency-based training. General Surgery residents and student nurse anesthetists were enrolled. Evaluation consisted of cognitive tests, procedure checklists and questionnaire.

Results

In total, 78 participants successfully completed the ASAC. Trainees agreed that the curriculum provided the cognitive and psychomotor skills necessary to perform both an open and needle cricothyroidotomy.

Conclusions

In the age of increased patient safety concerns, QAPI initiatives can serve as a driver for simulation-based training curricula, with particular focus on individualized, active learning. This may be particularly useful in high risk, low frequency scenarios in which the traditional method of “See one, Do one, Teach one,” is not feasible.

Introduction

Simulation has become a cornerstone in surgical education, with dedicated simulation experience now required by the Accreditation Council for Graduate Medical Education for all surgical programs. The advent of the 80-h work week, combined with the continued five-year training paradigm, has created a gap in surgical training and experience.¹ We have certainly observed a shift from the Halsted inspired, “See one, Do one, Teach one,” to a more active, contextualized process of constructing knowledge and entrusting task performance. The role of simulation in education is evolving with strong and varying opinions as to the ideal how, when, and whom concerning design and implementation.² Several studies have strived to determine the best form of curriculum implementation and in the process, outline the various challenges faced.³^,⁴^,⁵^,⁶ While the ideal form of implementation is debated, it is likely that simulation will remain embedded in surgical education for many years to come.²

In addition to the gap in surgical training experience, a large driving force for surgical simulation is patient safety.³ In the present healthcare environment, hospital administrators are now focusing on certain quality measures linked to patient outcomes and process of care, since payments are increasingly tied to outcome measures (i.e. catheter and central line related infections). Surgical simulation aims not necessarily to replace hands-on training and experience, but to augment the traditional taxonomy of learning by providing deliberate opportunities for practice outside of the operating room.⁷ The goal is to decrease the learning curve in both low frequency and high risk surgical procedures, with the hope of improving patient safety and outcomes.

Section snippets

Curriculum development

The residency advisory committee (RAC) of the department of Surgery at Rush University Medical Center initiated a proficiency based curriculum during the 2016/2017 Academic year. This curriculum, following guidelines from the American College of Surgeons (ACS) division of education, focused on common ICU procedures including needle cricothyroidotomy, arterial line placement, central venous catheter placement, and tube thoracostomy.⁸ Initially, this curriculum focused on junior surgical

Results

Following a pilot course given to senior anesthesia residents, 78 participants completed the ASAC, out of which thirty-two participants were junior (PGY-1 or PGY-2) surgical residents: nine (9) PGY-2 categoricals, eight (8) PGY-1 categoricals, and fifteen (15) PGY-1 preliminary residents. Twenty-four participants were senior (PGY-3, PGY-4, or PGY-5) surgical residents, all of them categorical. The remaining 22 participants were student nurse anesthetists. Within the junior resident group, the

Discussion

K. Anders Ericsson in his address “Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains.” defined principles that are applicable to the use of simulation in surgical education.⁹ Several other authors have described the crucial elements required in simulation-based curriculum design, including Aggarwal, Stefanidis and Heniford.³^,¹⁰ They describe a framework that combines cognitive learning with simulation, allowing for training to

Conclusion

In an age of increased safety concerns and measures, QAPI initiatives can serve as a driver for simulation-based training curricula. We demonstrated the feasibility of designing and implementing a mandatory surgical airway course, highlighting the challenges faced. While clinical scenarios that are high risk, low frequency are well suited for simulation based training, measuring the effectiveness of the simulation via patient outcome metrics remains elusive.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Cited by (11)

Expanding scope of Kirkpatrick model from training effectiveness review to evidence-informed prioritization management for cricothyroidotomy simulation
2023, Heliyon
Modified Kirkpatrick model has been adopted to evaluate training effectiveness by 6 categories, including activity accounting (training objectives/success in organization change) at Level-0, reaction (satisfaction) at Level-1, learning (acquisition of surgical airway skills) at Level-2, behavior (post-training change in personal strengths) at Level-3, result (organizational or clinical outcomes) at Level-4, and Return on Investment (ROI) or Expectation (ROE) (monetary and societal values following training and other quality and safety related measures) at Level-5. The purpose of this hospital-based prospective observational study was twofold: i) To evaluate potential impacts on monetary and societal values and successful organization change following implementation of advanced Cricothyroidotomy simulator and standardized curriculum in healthcare simulation training, ii) To inform decisions of resource allocation by reviewing overall values and prioritization strategies for i) general surgeon/emergency physician ii) with seniority >5 years and iii) prior porcine training experience based on findings at Kirkpatrick Level-0, Level-4, and Level-5. Seventy doctors and 10 nurses completed Cricothyroidotomy training and follow-up questionnaires within 2021/22. All training usability scoring measured by Scales of Emergency Surgical Airway Simulator (SESAS-17) achieved over 4 out of 5 (Level-4) with effects in favor of emergency physicians or general surgeons (p < .5), regardless of seniority and prior training experience. Success in organization change (Level-0) and cost-effectiveness (Level-5) were hypothetically established using theoretical framework of Gleicher's formula and Roger's Diffusion of Innovation Theory. Overall training effectiveness, in terms of advantage in usability, cost-benefits and successful organizational changes, provided sound evidence to support continuous investment of new curriculum and innovative simulator and “Surgeon-and-emergency-physician-first” policy when it comes to resources allocation strategies for Cricothyroidotomy training. [ACGME competencies: Practice Based Learning and Improvement, Systems Based Practice.]
Harnessing power of simulation training effectiveness with Kirkpatrick model in emergency surgical airway procedures
2022, Heliyon
Citation Excerpt :
Needs of developing a simulator for medical professionals to practice this “low frequency but high impact procedure” have been identified in military and hospital. However, the knowledge gap in choosing or validating simulators was large, not to mention how it affects training effectiveness nor how it brings positive impact on organization management [14, 15, 16]. Since 2013, Cricothyroidotomy had been incorporated into a local “Advanced Surgical Trauma Course” where pig larynx-trachea models were used as a traditional training modality.
Training effectiveness indicates how good a program has met pre-set training objectives or organizational goals for the best benefit of healthcare professionals and service users in the community. The study aimed to evaluate training effectiveness following implementation of new training curriculum of emergency surgical airway procedures (Cricothyroidotomy) organized by the Queen Elizabeth Hospital.
This training evaluation relied on observational descriptive study design. Timed task on Cricothyroidotomy procedures and standardized post-training questionnaire were applied to assess the first 3 levels of Kirkpatrick's model: (Level-1) Reaction by training satisfaction; (Level-2) Learning by acquisition of knowledge and skills assessment passing rate; (Level-3) Behavior by personal strengths.
This program was operated in the Multi-Disciplinary Simulation and Skills Centre, a hospital-based high-fidelity simulation training center accredited by the Society for Simulation in Healthcare.
The study recruited 80 trauma service providers, including 35 general surgeons, 15 emergency physicians, 10 anesthesiologists or intensivists, 6 neurosurgeons, 4 orthopedic surgeons, and 10 emergency nurses from five trauma centers under the Hospital Authority. All underwent the Advanced Trauma Life Support training in advance.
Compared with reference score from previous training sessions, the result of program using new training curriculum and simulator demonstrated significant training satisfaction of participants (Level-1), and high level of assertiveness, mental preparedness, self-efficacy, and internal locus of control and responsibility (p < .01, for all in Level-3). All participants (N = 80) completed entire Cricothyroidotomy procedure in 2 min without technical errors (Assessment passing rate = 100%) (Level-2).
Under Kirkpatrick model, simulation training in Cricothyroidotomy procedure using new curriculum and simulators has been proven to be useful for healthcare professionals involved in trauma service management. The result suggests that application of a state-of-the-art training tools to advanced surgical skills training could improve training satisfaction, knowledge and skills acquisition, and personal strengths transferable to clinical practice.
Practice Based Learning and Improvement.
Pediatric Surgery Simulation-Based Training for the General Surgery Resident
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Over the last 20 y, surgical training has significantly evolved. The traditional approach has been challenged by increasing financial restraints, regulation, concern for patient safety, the need for efficiency, the requirement of attending surgeons in the OR, the implementation of an 80-h work week, and a push for further subspecialization, among others.2,4,5 Consequently, on graduation, residents feel less prepared to operate autonomously and program directors and attending surgeons feel residents may be inadequately trained.1,4,27,28
Surgical simulation-based training (SBT) can increase resident confidence and improve performance. SBT in pediatric surgery is in its infancy and often geared toward training pediatric surgery fellows. Since case volume for various pediatric surgery–specific procedures can be low based on the rarity of the pathology involved and the level of care provided by the institution, our aim was to create a pediatric surgery simulation-based curriculum for general surgery residents to address this need.
We performed an institutional needs assessment consisting of 4 pediatric surgeons' and 28 general surgery residents’ confidence in resident ability to independently perform pediatric surgery–specific tasks and procedures using a Likert-scaled survey. These included the placement of a silastic silo for gastroschisis, a percutaneous drain for perforated necrotizing enterocolitis, and completion of a laparoscopic pyloromyotomy for pyloric stenosis. Models simulating these pathologies and curriculum for performing each procedure were generated.
We successfully created a model and SBT curriculum to teach general surgery residents how to place a silastic silo for patients with gastroschisis, a percutaneous drain for patients with perforated necrotizing enterocolitis, and how to complete a laparoscopic pyloromyotomy for patients with pyloric stenosis. These were deemed high fidelity models based on a survey of our pediatric surgeons.
We created a pediatric surgery SBT curriculum for general surgery residents, which can be used to supplement learning of various high-acuity, low-occurrence procedures. Assessment of residents and validation of scores is underway.
Implementing a QAPI framework for improvement in an academic setting: A roadmap to success
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The QAPI framework was intended to help improve processes involved in health care delivery and resident quality of life in nursing homes. While the QAPI process was originally designed for use by nursing homes, the methodology has since been used in other healthcare settings, and it is commonly the framework hospitals employ for quality improvement initiatives (Fisher et al., 2020; Mathur et al., 2019; Veenstra et al., 2019; Givens, 2018; Mathur & Talwalkar, 2017). The QAPI framework is the coordinated application and merger of two interconnected and complementary aspects of a quality management system: quality assurance (QA) and performance improvement (PI).
Designation as an accredited school of nursing (SON) requires “…. a comprehensive framework for ensuring quality in nursing education programs” (NLN CNEA, 2016). Although standards for accreditation of baccalaureate and graduate nursing programs are defined by agencies such as the Commission on Collegiate Nursing Education (CCNE, 2018) and the National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA) (NLN CNEA, 2016), methods for collecting, analyzing, or reporting data are not prescribed, resulting in wide variation in quality management processes among schools. The lack of a standardized approach can lead to inefficiencies, invalid or misleading data, and unnecessary stress for all involved in the quality management process (Hanna, Duvall, Turpin, Pendleton-Romig, & Parker, 2016). In contrast, hospitals and nursing homes frequently implement a quality assurance and performance improvement (QAPI) program, a well-defined, methodical approach to quality management. The QAPI model offers healthcare organizations a systematic, comprehensive, and data-driven strategy for maximizing outcomes (Centers for Medicare & Medicaid Services (CMS), 2016). Recognizing the need to improve and standardize the processes for data collection, analysis, and reporting, this paper describes how leaders at one accredited SON collaborated to translate CMS's QAPI model into the academic setting, establishing the foundation and mechanism to ensure the quality and integrity of the SON's outcomes.
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The emergency surgical airway: Bridging the gap from quality outcome to performance improvement through a novel simulation based curriculum

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Curriculum development

Results

Discussion

Conclusion

Funding

J Am Coll Surg

Am J Surg

Am J Surg

J Am Coll Surg

A consensus-based framework for design, validation, and implementation of simulation-based training curricula in surgery

J Am Coll Surg