year one outcomes assessment of a masters suturing and knot tying program for surgical interns

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YEAR ONE OUTCOMES ASSESSMENT OF A MASTERS SUTURING AND KNOT TYING PROGRAM FOR SURGICAL INTERNS 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

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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 Presentation

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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

Masters Program Structure

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

Acknowledgements

M Schill was supported by NIH grant T35 DK074375-05