year one outcomes assessment of a masters suturing and knot tying program for surgical interns
DESCRIPTION
Matthew Schill, BS, Debbie Tiemann, RN, Mary Klingensmith, MD, L. Michael Brunt, MD Department of Surgery and Institute for Minimally Invasive Surgery Washington University School of Medicine St. Louis, MO. - PowerPoint PPT PresentationTRANSCRIPT
YEAR ONE OUTCOMES ASSESSMENT OF A MASTERS SUTURING AND KNOT TYING
PROGRAM FOR SURGICAL INTERNSMatthew Schill, BS, Debbie Tiemann, RN,
Mary Klingensmith, MD, L. Michael Brunt, MD
Department of Surgery and Institute for Minimally Invasive Surgery
Washington University School of Medicine
St. Louis, MO
Disclosures Matthew Schill:
No relevant financial interests L. Michael Brunt, MD:
MIS Fellowship Grant Support:○ Ethicon Endosurgery
Honorarium/Speaking: ○ Lifecell Corp
Background
Simulation is increasingly important in surgical education
Surgical residents may suffer in skills acquisition for many reasons:Work hour restrictionsOR time constraintsPatient safety concernsIncreasing complexity of surgical patients
and surgical technology
Background Basic suturing and knot tying are essential for
surgical skills development
Technical skills of incoming PGY-1 residents may vary widely due to prior experiences
Suturing and knot tying skills sessions are commonly taught but without further formal instruction, specified practice or assessment
Development of these skills progresses primarily along a Halstedian model of training in the OR
Background
Since 2001 our Department has held an introductory suturing and knot tying skills session for beginning surgical interns
In 2009, we restructured this program to include further instruction, defined goals and proficiency targets, and assessment of performance
Goal to develop cohort of trainees who have undergone the same training and performance template (“Masters” Program)
Hypothesis
Feedback, remediation and further practice would be necessary to meet the desired performance levels
Specific Aims
1. Describe elements of this “Masters” program
2. Report year one outcomes data
3. Correlate skills performance with conventional performance measures (case volumes, intern rotation evaluations, and ABSITE scores)
Masters Program Structure:Skills Training Template 2-hour skills training session
Lecture and hands-on
Materials for practiceSuture pad and tying boardInstrument set
Online videos available for self-study
Follow-up skills training session at 2.5 months
Tasks Suturing tasks:
Simple interruptedSubcuticularVertical mattress
Tying tasks:One-handedTwo-handedTie on a pass
Assessment
Timed and video taped technical performance (TP) of six tasks
Pre-course, 4 months post-course and thereafter as needed
All videos reviewed and scored by one senior surgeon (LMB) blinded to the intern using OSATS format
Other Performance Measures Case numbers at 4 and 10 months
Technical skill comments from resident rotation evaluations graded on 1-5 scale
ABSITE scores PGY-1 year
Participants 9 surgical interns (8 categorical and 1 non-
designated) at Washington University Medical Center participated in the program
6 end of PGY-2 Categorical General Surgery residents were assessed for comparison
Washington University School of Medicine Human Studies Committee approved protocol
Data Analysis
All data are mean ± SD
Statistical analysis:Task completion time: ANOVA with Tukey
post-hoc testsTechnical proficiency: Kruskal-Wallis testComparison with other measures: Pearson
correlationp-value of < 0.05 was considered significant
Results: Demographics
Mean age: 27 ± 2.4 years
Gender: male – 6, female – 3
Handedness: right – 8, left – 1
None had participated in an intern preparedness skills course as 4th year medical students
Suturing Task Times
Baseline 4 mos. Final PGY-20
100
200
300
400
Simple Interrupted SubcuticularVertical Mattress
Tim
e (
se
c.)
* denotes p < 0.05 rel-ative to baseline
* **
Tying Task Times
Baseline 4 mos. Final PGY-20
20
40
60
80
100
120
140
160
One-Handed Two-Handed Tie on Pass
Tim
e (
se
c.)
** *
**
* p < 0.05** p < 0.001 relative to baseline
Total Combined Task Time
Baseline 4 Months Final PGY-20
400
800
1200
1600
Tim
e (
se
c.)
**
* *p < 0.001 vs baseline
8½ minutes!
Suturing Technical Proficiency
Baseline 4 mos. Final PGY-20
1
2
3
4
5
Simple Interrupted SubcuticularVertical Mattress
TP
Sc
ore
*** p < 0.05 vs baseline
Tying Technical Proficiency
Baseline 4 mos. Final PGY-20
1
2
3
4
5
One-Handed Two-Handed Tie on Pass
TP
Sc
ore
* * ** p < 0.05 vs baseline
Time to Proficiency All interns reached proficiency targets on 6/6 tasks
Mean time to proficiency: 10.1 months (4-12 months)
Mean # assessments post-training: 2.4 (range 1-3)
Proficiency rates at 4 mos:Suturing tasks: 44-55%Tying tasks: 11-22%Only one intern proficient on all 6 tasks at 4 month
assessment
Conventional Performance Measures
Case counts at 4 and 10 months, and ABSITE did not correlate with time or TP
Coded rotation comments pertaining to technical skills were inversely correlated with total combined task time (not TP scores)
Study Limitations
Small sample size
Absence of control intern group
Technical proficiency assessment by one evaluator
Impact on operative technical performance unknown
Summary Feedback, remediation, and repetitive practice
are necessary for surgical interns to reach proficiency levels on basic suturing and knot tying tasks
Performance levels on these fundamentals upon completion of this program are comparable to that of end of R-2 year residents
Most traditional measures of intern performance correlate poorly with formal technical skills assessment
Conclusions
Proficiency based training and objective assessment of performance should be more widely utilized early in residency training for these fundamental surgical skills