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BACKGROUND: Ward-based care of surgical patients is a complex and variable process, centered on the surgical ward round (WR). The authors describe the development of an evidence-based curriculum to improve ward-based care in the form of surgical WRs. METHODS: A modular, simulation-based curriculum was developed according to validated methods, incorporating the most recent evidence in the design of each educational module. RESULTS: A predevelopmental analysis questionnaire identified themes of patient assessment and management, communication skills, and teamwork as areas to be addressed. Curricular development incorporated knowledge and confidence assessment, lecture-based teaching, and simulated WR, followed by individualized assessment, debriefing, and feedback. Each module is evidence based and assesses trainees using validated tools. CONCLUSIONS: A comprehensive and cost-effective simulation-based curriculum, developed according to a validated framework, has been developed for surgical WRs and ward-based care. This may improve trainees' WR performance, improving patient care and surgical outcomes in turn. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The use of aptitude tests in the selection of surgeons has gained recent attention. Few have described its relevance in predicting the acquisition of surgical techniques. We aim to show whether assessing manual dexterity can predict the quality of the final product after a period of training. Methods: Thirty-six medical students had their manual dexterity assessed completed bench model small bowel anastomosis in 8 consecutive sessions. The fine details (accuracy (number of sutures that traversed full thickness) and number of sutures placed) and gross details (bowel apposition) of quality of final product was objectively assessed. Results: Manual dexterity correlated with grade only in the initial sessions (Pearson correlation coefficient, r = −.578, P < .01). There was no significant correlation with the fine details with any session. Conclusions: There was a correlation with manual dexterity and outcome measures in the initial sessions of training with grade only. This relationship was eliminated by the end of training sessions. This suggests that the outcome of procedures after a period of training cannot be predicted by measuring manual dexterity skills. [Copyright &y& Elsevier]

Abstract: Background: Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships. Methods: Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons''/medical students'' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set. Results: Post-feedback, both groups'' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further. Conclusions: Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making. [Copyright &y& Elsevier]

Abstract: Background: Training surgeons in vital decision-making skills remains unstructured. We aimed to map a process of care from the perspective of surgical decision making and test whether it could be deconstructed into an accessible format for trainees. Methods: Semistructured interviews were conducted with 10 experienced surgeons by using symptomatic gallstones as a clinical exemplar. Data were analyzed by 2 independent reviewers to identify decisions, cues, and decision rules, with further thematic analysis of selected decisions. Results: Eighteen specific decisions were identified in 6 or more transcripts, with significant interreviewer reliability (Spearman''s ρ = .65, P = .004, n = 17, 1 outlier excluded). These were arranged to form a “decision map.” Two main decision strategies were described. Conclusions: We identified and mapped the decisions made in the care of patients with symptomatic gallstone disease. The interpretation of competency at any procedure should include the surgeon''s ability to make appropriate decisions at all stages of patient care. [Copyright &y& Elsevier]

Background Postoperative complications are common. Inconsistency in the care of complications is reflected in variable rates of failure to rescue. This study aims to develop and validate checklists for treatment of common postoperative complications. Methods Initial checklists were based on best evidence, with expert clinician review. Casenote review was performed, comparing checklist item completion with outcomes. Logistic regression was performed for risk of further morbidity, considering American Society of Anesthesiology grade, age, sex, and checklist compliance. Checklists were finalized through end user multidisciplinary review. Results Evidence-based checklists were developed. Retrospective casenote review revealed management of 86% (31/37) of these complications to be noncompliant with checklist-mandated care. This resulted in delays and errors in 65% (24/37) of cases, with median treatment delay of 6 hours (interquartile range 5.4 hours). Regression analysis revealed poor checklist compliance to be to only significant factor (odds ratio 6.75, 95% confidence interval 1.11 to 41.00, P = .038) for developing further morbidity. Conclusions Management of complications is highly variable, with failure to adhere to best practice principles significantly associated with an increased risk of further morbidity. This study presents an evidence-based framework for the development of checklists to standardize care. [ABSTRACT FROM AUTHOR]

BACKGROUND: The surgical ward round (WR) represents the primary interface between the clinical team and the patient and is integral to the quality of postoperative care and subsequent patient outcomes. This study aims to explore key issues pertaining to the surgical WR, defining challenges in current practice, and identifying potential means of quality assessment and improvement. METHODS: A qualitative, semistructured interview-based approach was adopted, including patients, nurses, interns, residents, and attendings. RESULTS: Twenty-five interview subjects were recruited across 8 hospitals. Twenty-three of the 25 (92%) subjects believed that there was significant variation in the quality of WRs and that this affected patient care. Lack of thoroughness (18/25, 72%) and poor communication (12/25, 48%) were the most commonly identified causes. Nontechnical skills such as communication (25/25, 100%) were seen as crucial to WR quality. Quality markers for surgical WRs were identified. Simulation-based training was recommended (13/25, 52%) to improve performance. CONCLUSIONS: Clinical staff and patients alike perceive there to be significant variability in current surgical WR practice. Further development of interventions to assess and improve surgeons' performance is necessary to standardize and improve WRs and patient care. [ABSTRACT FROM AUTHOR]

BACKGROUND: Ward round skills are essential for the best management of surgical inpatients, but assessment of their quality has received inadequate attention. This study aims to design and validate the surgical ward round assessment tool (SWAT). METHODS: We used modified Healthcare Failure Mode and Effects Analysis to develop the SWAT by identifying ward round steps. We assessed the validity of the SWAT using simulated and real surgical ward rounds. RESULTS: The Healthcare Failure Mode and Effects Analysis identified 30 ward round steps that were developed into the SWAT. Nineteen surgeons completed simulated surgical ward rounds. Eight fully trained surgeons scored significantly higher than 11 trainee surgeons when assessed with the SWAT (P5 .001). On average, the participants thought the realism of the simulation was good. Forty-four surgeons completed real surgical ward rounds. Fifteen experts scored significantly higher than 29 trainee surgeons when assessed with SWAT (P 5 .001). Inter-rater reliability was .85 to .89, respectively. CONCLUSIONS: The SWAT can be used to assess the quality of task-based and nontechnical surgical ward round skills. [ABSTRACT FROM AUTHOR]

BACKGROUND: Outdated communication technologies in healthcare can place patient safety at risk. This study aimed to evaluate implementation of the WhatsApp messaging service within emergency surgical teams. METHODS: A prospective mixed-methods study was conducted in a London hospital. All emergency surgery team members (n = 40) used WhatsApp for communication for 19 weeks. The initiator and receiver of communication were compared for response times and communication types. Safety events were reported using direct quotations. RESULTS: More than 1,100 hours of communication pertaining to 636 patients were recorded, generating 1,495 communication events. The attending initiated the most instruction-giving communication, whereas interns asked the most clinical questions (P < .001). The resident was the speediest responder to communication compared to the intern and attending (P < .001). The participants felt that WhatsApp helped flatten the hierarchy within the team. CONCLUSIONS: WhatsApp represents a safe, efficient communication technology. This study lays the foundations for quality improvement innovations delivered over smartphones. [ABSTRACT FROM AUTHOR]

BACKGROUND: The implementation of duty-hour restrictions and a heightened awareness of patient safety has changed resident education and training. A new focus has been placed on high-yield training programs and simulation training has naturally grown to fill this need. METHODS: This article discusses the development of a training framework, knowledge, skills, and attitudes, and the design of a surgical simulation curriculum. Five residents were recruited for a pilot study of the curriculum. RESULTS: A successful framework for curriculum development was implemented using laparoscopic cholecystectomy as the example. The curriculum consisted of classroom and virtual reality simulation training and was completed in 3.1 to 4.8 hours. CONCLUSIONS: The current curricula that have been developed for surgical education cover the breadth of a surgical residency well. This curriculum went beyond these curricula and developed a structured framework for surgical training, a method that can be applied to any procedure. [ABSTRACT FROM AUTHOR]

BACKGROUND: To improve surgical training standards, it is necessary to first define the elements of high-quality training and methods for measuring them. METHODS: Semistructured interviews were conducted with attending (n 5 10) and resident (n 5 10) general surgeons. An interview topic guide was used to elicit end users' opinions on indicators of training quality and methods to measure them. Interviews were recorded, transcribed verbatim, and coded using a framework to identify emergent themes. Sampling ceased once thematic saturation was achieved. RESULTS: Key surgical training quality indicators include continuity (80% of participants) and relationship (95%) between trainee and trainer, level of supervision (85%), and an optimal volume (95%) and mix (90%) of operative cases. All surgeons felt that trainee logbook analysis and feedback was essential. The majority (85%) felt that training analysis should be freely available to create accountability for hospitals and attending surgeons (70%) and encourage competition (70%) to drive up standards. Only 30% felt that all attending surgeons should offer training. CONCLUSIONS: Surgical training quality needs to be robustly assessed. Transparency in training outcomes will create competition and raise standards of surgical education. [ABSTRACT FROM AUTHOR]

Abstract: Background: Assessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment. Methods: Included studies reported tools for observational assessment of technical skills. A total of 106 articles were included. Results: Three main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse. Conclusions: There is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level. [Copyright &y& Elsevier]

Abstract: Background: The surgical master class is a traditional method for a surgeon to learn new operations. However, there is limited evidence to support that it can help a surgeon adopt a new technique. The aim of this study was to investigate the adoption of surgical techniques after attendance at a surgical master class. Methods: A questionnaire was sent to surgeons attending surgical master classes in laparoscopic bariatric and colorectal surgery. The questionnaire examined operative experience before attending the master class and the consequent adoption of techniques. Results: There was a significant adoption of colorectal procedures, from 33% to 79% (P = .00011), and bariatric procedures, from 27% to 66% (P = .014), after attendance at the surgical master classes. Conclusions: This study shows a significant increase in surgeons'' performing advanced surgical procedures after attendance at a surgical master class. This is the first study to demonstrate the effectiveness of the master class in terms of surgeons'' adopting new techniques. [Copyright &y& Elsevier]

Abstract: Background: This study assessed the implementation of a theater induction curriculum through a didactic lecture, an online Second Life operating room, and a simulated operating suite. Methods: Sixty operating room novices were randomized into 4 groups: control (n = 15), didactic lecture (n = 15), Second Life (n = 15), and simulated operating suite (n = 15). The study followed a pretest and posttest design with a training intervention between operating room attendances. Outcome measures were knowledge, skills, and attitudes, measured using observed behavior and a self-report scale, with knowledge further assessed using multiple-choice questionnaires. Results: The lecture, Second Life, and simulated operating suite groups demonstrated significant improvements in all outcome measures. After the intervention, these 3 groups had significantly higher behavior (P < .001), self-report (P < .05), and knowledge (P < .05) scores than the control group. Conclusions: This study demonstrates the value of delivering a theater induction curriculum for operating room preparation. [Copyright &y& Elsevier]

Abstract: Background: Laparoscopic antireflux surgery is an accepted treatment for persistent gastroesophageal reflux but about 4% of patients will eventually require revision surgery. Methods: We searched The Cochrane Collaboration, Medline, and EMBASE databases, augmented by Google Scholar and PubMed related articles from January 1, 1990, to November 22, 2010. Twenty studies met the inclusion criteria, reporting on 930 surgeries. Results: The mean surgical duration was 166 minutes and conversion to open revision fundoplication was required in 7% of cases. Complications were reported in 14% of cases and the mean length of stay varied between 1.2 and 6 days. A good to excellent result was reported for 84% of surgeries and 5% of patients required a further revisional procedure. Conclusions: Laparoscopic revision antireflux surgery appears to be feasible and safe, but subject to somewhat greater risk of conversion, higher morbidity, longer hospital stay, and poorer outcomes than primary laparoscopic fundoplication. [Copyright &y& Elsevier]

Abstract: Background: Postsurgical pain is a major cause of delayed recovery and discharge after surgery. A significant proportion of patients develop chronic postsurgical pain, which affects their quality of life. Cognitive and psychological factors are reported to play a significant role in the severity of reported postsurgical pain. High levels of catastrophizing are associated with a heightened pain experience and appear to contribute to the development of chronic pain. This article describes the concept of pain catastrophizing, its association with postsurgical pain, and its potential role in the management of postsurgical pain and postsurgical quality of life. Methods: Data for this review were identified from MEDLINE, EMBASE, and PsycINFO. Reference lists of selected articles were cross-searched for additional literature. Results: High catastrophizing levels were found to be associated with increased pain severity, increased incidence of development of chronic pain, and poorer quality of life after surgery. There was no consensus on the relation between catastrophizing and analgesia consumption. Conclusions: Identifying and reducing catastrophizing levels can help to optimize pain management in surgical patients. [Copyright &y& Elsevier]

Abstract: Background: Several techniques have been described for the management of fistula-in-ano, but all carry their own risks of recurrence and incontinence. Technology has evolved over the past 2 decades that may enable surgeons to deal with this troublesome issue with greater success. This review summarizes the history of fistula-in-ano management, the current techniques available, and describes new technologies. Methods: Medline searches were performed using the PubMed, Ovid, Embase, Cochrane, and Google Scholar databases to identify articles reporting on fistula-in-ano management using surgery alone, fibrin glues, and fistula plugs. Forty-one articles reporting on the history of fistula-in-ano management and the use of new technologies were included. Results: Conventional fistula surgery techniques have their place, but new technologies such as fibrin glues and the anal fistula plugs offer an alternative approach, with initial studies reporting good success rates. Conclusions: New technologies provide promising alternatives to traditional methods of management. There is, however, a real need for high-quality randomized control trials. [Copyright &y& Elsevier]

Abstract: Background: The aim of this study is to describe a single institution’s experience in the use of transanal endoscopic microsurgery for rectal tumors. Methods: Between 1996 and 2005, transanal endoscopic microsurgery was performed in 76 patients. The histologic diagnosis was adenoma in 48 and adenocarcinoma in 28 patients. Results: Clear resection margins were achieved in 71 of 74 patients (95.9%). Overall morbidity was 18.9% because 14 patients developed minor (10 patients) or major complications (4 patients). During the follow-up, benign tumor recurrence was detected in 3 patients (6.3%). The recurrence rates among patients with T1, T2, and T3 malignant tumors were 7.1%, 42.8%, and 66.6%, respectively. Comments: Transanal endoscopic microsurgery is a safe and feasible technique with low incomplete excision rates and may be the preferred method in patients with benign rectal tumors. Its role in the management of malignant tumors should be limited to selected patients with T1 lesions. [Copyright &y& Elsevier]

Background: Assessment of surgical competence is a priority; however little is known about surgeons' perceptions of competence. We investigated components of competence and adequacy of training in achieving them., Methods: Using questionnaires, Surgical Attendings and trainees rated the importance of 7 CanMEDS roles that define a competent surgeon (Medical Expert; Communicator; Collaborator; Manager; Health Advocate; Scholar; Professional) and whether training enabled them to achieve competency in each role., Results: Ninety-two of 125 questionnaires (74%) were completed. Junior trainees attributed lower importance to the roles of Manager, Communicator, Collaborator, and Professional than senior trainees or Attendings. No surgeon stated that they had achieved competency in every role., Conclusion: Trainee surgeons do not appreciate the importance of all the roles required of a competent surgeon and current training does not ensure competence in all roles. These gaps must be addressed to develop surgeons able to provide the highest quality of care.