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Background: No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.Method: This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).Results: Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.Conclusion: Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Background The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks. Methods A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three-stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income. Results In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis. Conclusion Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.

SESSION TITLE: Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To evaluate the practice of creation of tracheostomies during the initial phases of the COVID-19 pandemic, with a focus on clinical outcomes and sedation parameters METHODS: We enrolled 45 consecutive COVID-19 positive adult patients whom a consult for tracheostomy was placed at Johns Hopkins Hospital between 4/16/2020 and 5/22/2020 A total of 38 tracheostomies were performed at the time of censoring Five of the patients were extubated before performance of tracheostomy and two were awaiting creation of tracheostomy Data was collected via manual extraction on clinical outcomes, sedative medication use for the 48 hours pre- and 48 hours post-tracheostomy RESULTS: Baseline characteristics of the 45 patients include a median age of 62, BMI of 30, with an even split of Male:Female (23:22) The median days of intubation before tracheostomy was 20 (range: 5-36), median days from consult for tracheostomy to performance of tracheostomy was 3 A multidisciplinary team across specialties performed the tracheostomy consults with Interventional Pulmonary performing 18, Otolaryngology 13, General Surgery 9, Thoracic Surgery 5 29 of the tracheostomies were performed percutaneously A bronchoalveolar lavage, tracheal aspirate, or sputum sample was obtained on the day of performance of the tracheostomy and 35 of the 38 were negative for COVID-19 The samples were sent a median of 23 5 days after the initial positive test Mortality on date of censoring was 7 (15 6%) including 5 (13 2%) of the patients with tracheostomy 10 (22 2%) had been discharged including 9 (23 7%) of the patients with tracheostomy Sedation and analgesia (total dose in 48 hours pre- (PR) and 48 hours post post-tracheostomy (PO)) expressed as median dosage for patients receiving that medication:- Dexmedetomidine (mcg/kg/hr): PR (18 patients): 28 7;PO (17 patients): 27 4- Midazolam (mg): PR (7 patients): 82 6;PO (8 patients): 55 5- Fentanyl (mcg): PR (21 patients): 450 0;PO (19 patients): 618 75- Propofol (mcg/kg/min): PR (8 patients): 1245 2;PO (5 Patients): 84 4 CONCLUSIONS: In the early-phase of the COVID-19 pandemic 38 patients with COVID-19 induced respiratory failure underwent successful tracheostomy The median length of intubation prior to tracheostomy was 20 days, longer than our historical average, likely related to initial concerns over performing this high-risk aerosolizing procedure The total dosage of each sedative medication decreased from the 48 hours pre- and post-tracheostomy, potentially related to endotracheal tube removal CLINICAL IMPLICATIONS: We were able to show that performance of tracheostomy during COVID-19 is safe and can be approached from multiple specialties Early tracheostomy should be considered in appropriate patients to reduce cumulative sedative medication dose, length of intubation, length of ICU stay, and cost of admission DISCLOSURES: No relevant relationships by Esther Ben Or, source=Web Response No relevant relationships by Nasir Bhatti, source=Web Response Consultant relationship with Veracyte, Inc Please note: $1001 - $5000 Added 04/01/2020 by David Feller-Kopman, source=Web Response, value=Consulting fee No relevant relationships by Elliott Haut, source=Web Response Receive Research Support relationship with Medtronic Please note: >$100000 Added 05/31/2020 by Alexander Hillel, source=Web Response, value=Grant/Research No relevant relationships by Chris Kapp, source=Web Response research, consultant relationship with Veran Please note: 2016-ongoing by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Research, Consultant relationship with Veracyte Please note: 2017- Present by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response President relationship with Association of Interventional Pulmonary Program Directors Please note: 2017-2019 by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Consu tant relationship with Veran Medical Please note: 2016-Present by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Consultant relationship with Veracyte Please note: 2018-Present by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Research relationship with Veracyte Please note: 2017-Present by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Research, Consultant relationship with Coridea Please note: 2017-Present by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Education relationship with Intuitive Please note: 3 days by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Consultant relationship with Veracyte Please note: 2018 to present by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Advisory Board relationship with Veracyte Please note: May 2019 (1 day) by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Focus Group relationship with Cook Medical Please note: May 2019 (1 day) by Hans Lee, source=Web Response Removed 06/11/2020 by Hans Lee, source=Web Response Consultant relationship with Merit Medical Please note: 2019 Added 06/11/2020 by Hans Lee, source=Web Response, value=Honoraria Consultant relationship with Cook Medical Please note: 2019 Added 06/11/2020 by Hans Lee, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Veracyte Please note: Consulting fee Added 06/11/2020 by Hans Lee, source=Web Response, value=Honoraria No relevant relationships by Laeben Lester, source=Web Response No relevant relationships by Jacqueline Stokes, source=Web Response no disclosure submitted for Jeffrey Thiboutot;No relevant relationships by Lonny Yarmus, source=Web Response, value=Grant/Research Support Removed 05/31/2020 by Lonny Yarmus, source=Web Response No relevant relationships Added 04/27/2020 by Lonny Yarmus, source=Web Response, value=Grant/Research Support Removed 05/31/2020 by Lonny Yarmus, source=Web Response No relevant relationships Added 04/27/2020 by Lonny Yarmus, source=Web Response, value=Grant/Research Support Removed 05/31/2020 by Lonny Yarmus, source=Web Response No relevant relationships Added 04/27/2020 by Lonny Yarmus, source=Web Response, value=Grant/Research Support Removed 05/31/2020 by Lonny Yarmus, source=Web Response No relevant relationships Added 04/27/2020 by Lonny Yarmus, source=Web Response, value=Grant/Research Support Removed 05/31/2020 by Lonny Yarmus, source=Web Response No relevant relationships by Lonny Yarmus, source=Web Response Removed 04/27/2020 by Lonny Yarmus, source=Web Response No relevant relationships by Lonny Yarmus, source=Web Response Removed 04/27/2020 by Lonny Yarmus, source=Web Response No relevant relationships by Lonny Yarmus, source=Web Response Removed 04/27/2020 by Lonny Yarmus, source=Web Response No relevant relationships Added 04/27/2020 by Lonny Yarmus, source=Web Response, value=Grant/Research Support Removed 05/31/2020 by Lonny Yarmus, source=Web Response No relevant relationships by Lonny Yarmus, source=Web Response Removed 04/27/2020 by Lonny Yarmus, source=Web Response

Objective A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). Design The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. Setting Tertiary care academic hospital center Participants Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. Results Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p Conclusions Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course.

Purpose Few guidelines exist regarding the selection of a particular type or size of tracheostomy tube. Although nonstandard tubes can be placed over the percutaneous kit dilator, clinicians often place standard tracheostomy tubes and change to nonstandard tubes only after problems arise. This practice risks early tracheostomy tube change, possible bleeding, or loss of the airway. We sought to identify predictors of nonstandard tracheostomy tubes. Materials and methods In this matched case-control study at an urban, academic, tertiary care medical center, we reviewed 1220 records of patients who received a tracheostomy. Seventy-seven patients received nonstandard tracheostomy tubes (cases), and 154 received standard tracheostomy tubes (controls). Results Sex, endotracheal tube size, severity of illness, and computed tomography scan measurement of the distance from the trachea to the skin at the level of the superior aspect of the anterior clavicle were significant predictors of nonstandard tracheostomy tubes. Specifically, trachea-to-skin distance > 4.4 cm and endotracheal tube sizes ≥ 8.0 were associated with nonstandard tracheostomy. Conclusions The findings suggest that clinicians should consider using nonstandard tracheostomy tubes as the first choice if the patient is male with an endotracheal tube size ≥ 8.0 and has a trachea-to-skin distance > 4.4 cm on the computed tomography scan.

Students pursuing a medical career in the US are subject to standardized testing at regular intervals. These standardized tests not only quantify the milestones students have already achieved, but also define the path for future achievements. The purpose of these examinations is to help students become self-directed, lifelong learners - an essential attribute of a medical professional. However, whether preparing for these examinations actually makes students such disciplined learners needs to be examined. Especially during residency training with its limited time and unpredictable exposure, trainees must learn in the most efficient way for their learning styles, and thus develop attributes that will be helpful to them in their medical career. In this review, we propose that a personalized, learner-centered approach tailored to residents' educational needs and preferences can not only fulfill learning interests and objectives but also serve as a time-efficient and cost-effective approach for graduate medical education.

Objectives/Hypothesis Despite careful selection processes, residency programs face the challenge of training residents who fall below minimal performance standards. Poor performance of a resident can endanger both patient safety and the reputation of the residency program. It is important, therefore, for a program to identify such residents and implement strategies for their successful remediation. The purpose of our study was to gather information on evaluation and remediation strategies employed by different otolaryngology programs. Study Design Cross-sectional survey. Methods We conducted a national survey, sending a questionnaire to the program directors of 106 otolaryngology residency programs. We collected information on demographics of the program, identification of problematic residents, and remediation strategies. Results The response rate was 74.5%, with a 2% cumulative incidence of problematic residents in otolaryngology programs during the past 10 years. The most frequently reported deficiencies of problematic residents were unprofessional behavior with colleagues/staff (38%), insufficient medical knowledge (37%), and poor clinical judgment (34%). Personal or professional stress was the most frequently identified underlying problem (70.5%). Remediation efforts included general counseling (78%), frequent feedback sessions (73%), assignment of a mentor (58%), and extra didactics (47%). These remediation efforts failed to produce improvement in 23% of the identified residents, ultimately leading to their dismissal. Conclusions The apparent deficiencies, underlying causes, and remediation strategies vary among otolaryngology residency programs. Based on the results of this survey, we offer recommendations for the early identification of problematic residents and a standardized remediation plan. Level of Evidence NA Laryngoscope, 2015

Objectives/Hypothesis Evidence shows a positive association between quality of surgical training received and patient outcomes. Traditionally, improved patient outcomes are linked with increased operative volume. However, generalizing this finding to surgeons in training is unclear. In addition, reduced exposure due to work-hour restrictions calls for alternative methods to determine the quality of training. The purpose of this study was to identify the indicators of high-quality training by surveying the trainees and trainers. Methods A questionnaire was developed based on input from faculty and previous studies. The survey was divided into three sections asking about the indicators of quality training, methods to measure them, and interventions for improvement. The questionnaire was administered to program directors (PDs) and senior residents of otolaryngology training programs nationwide. Results The strongest indicators of quality training that were agreed upon by both residents and PDs were having faculty development as an ideal trainer while having a balanced level of supervision and independence, logbooks for exposure to volume and variety of pathology, continuous evaluation and provision of feedback. However, structured teaching, simulation-based training, and trainee exam scores failed to reach an agreement as a metric of high-quality surgical training. Conclusion Measuring quality of a residency training program is imperative to produce competent surgeons and ensuring patient safety. The results of this study will help the residency programs to better train their residents and improve the quality of their teaching. Level of Evidence N/A. Laryngoscope, 2015

Evaluation of surgical skills and competency are important aspects of the medical education process. Measurable and reproducible methods of assessment with objective feedback are essential components of surgical training. Objective Structured Assessment of Technical Skills (OSATS) is widely used across the medical specialties and otolaryngology-specific tools have been developed and validated for sinus and mastoid surgery. Although assessment of surgical skills can be time-consuming and requires human and financial resources, new evaluation methods and emerging technology may alleviate these barriers while also improving data collection practices.

Objectives/Hypothesis The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes. Study Design Retrospective review of prospectively collected data from the hospital's airway registry. Methods We collected data on demographics, airway characteristics, airway management techniques used by each specialty, and clinical outcomes (such as cricothyrotomies) for patients for whom a code was activated between July 2006 and June 2010. We compared data between pre- and post-DART cohorts and between DART and non-DART patients using a matched case-control approach. Results Of the 2,826 codes, 90 patients required DART management between July 2008 and June 2010. Body mass index, cervical spine injury/fixation, history of difficult airway, head and neck mass, and oropharyngeal and/or supraglottic angioedema were identified as significant predictors for DART activation. Forty-nine (60%) patients' airways were secured by anesthesiologists, 30 (36%) by otolaryngologists, and three (4%) by trauma surgeons. Otolaryngologists were able to use specialized techniques such as Holinger and Dedo laryngoscopes to significantly decrease the number of cricothyrotomies from seven (0.73%) pre-DART implementation to four (0.21%) post-DART implementation. Conclusions Otolaryngologists were able to decrease the need for cricothyrotomies using specialized techniques for patients with difficult airways. Otolaryngologists bring a special skill set to the DART that is beyond the scope of anesthesiologists and trauma surgeons and that can improve patient outcomes by preventing unnecessary emergency surgical airways. Level of Evidence 2b Laryngoscope, 125:640–644, 2015

OBJECTIVES/HYPOTHESIS: To measure the effect of distractions on the operative performance and analyze if practice and experience are the factors that can help to overcome the distractions. STUDY DESIGN: Prospective observational study. METHODS: Ten postgraduate year (PGY) 2-6 residents and two faculty members from Johns Hopkins' otolaryngology department were recruited and asked to deepen the dissection at the sinodural angle on the Voxel-man mastoidectomy simulator. They were asked to perform the task under four conditions: 1) no distractors, 2) differentiation and counting of a specific alarm sound among different sounds played in the background while performing the surgical task, 3) simultaneous performance of simple arithmetic task of moderate difficulty, and 4) simultaneous performance of the task with both sets of distractors combined. RESULTS: Time taken for the task (P = .02) and error scores (P = .002) increased under the third and fourth conditions. The ability to multitask and response to surgical and cognitive tasks improved with increasing level of experience of the participants. CONCLUSIONS: Distractions lead to impaired dexterity and an increase in the incidence of errors. However, experience and deliberate practice can help achieve the ability to multitask without compromising the operative performance. LEVEL OF EVIDENCE: NA Laryngoscope, 2014. Keywords: Driver distraction; Language: en

Objectives/Hypothesis To examine the effects of a learner-centered educational curriculum for Johns Hopkins otolaryngology–head and neck surgery residents in improving their otolaryngology training examination (OTE) scores. We hypothesized that trainees who attend a learner-centered program demonstrate improved performance on OTEs. Study Design Prospective longitudinal study. Methods In September 2008, a resident-designed educational curriculum was implemented to better prepare residents for their OTE. These mandatory sessions, led by faculty members, were held for an hour every week, during in which residents were tested on their knowledge of high-yield topics. Residents were expected to be prepared on pathophysiology, diagnosis, and treatment of the selected diseases. In 2011, residents were given responsibility to lead these sessions. OTE scores from 2002 to 2012 were analyzed to see whether there was any improvement after the implementation of this curriculum. Results Clustered linear regression analysis revealed significant improvement of OTE scores with subsequent interventions. During a 3-year period (2009–2011) after the first intervention, there was a significant increase (P = .01) of 0.69 in mean national and 0.78 in mean group stanine scoring. Similarly, after the second intervention in 2011, a further increment of 1.36 in mean national and 1.58 in mean group stanine scoring was seen (P = .001). Conclusions Residents OTE stanines improved significantly after the implementation of a learner-centered educational curriculum. This finding suggests that trainees are able to perform better when involved in planning and implementing the educational curriculum. Level of Evidence NA Laryngoscope 124:2262–2267, 2014

Objectives/Hypothesis To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. Study Design Descriptive review of quality improvement project. Methods A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. Results Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. Conclusion The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety. Level of Evidence 2b. Laryngoscope, 124:1794–1800, 2014

Objectives/Hypothesis The purpose of this study is to compare faculty and trainees' perceptions of their mentorship experience in otolaryngology training programs in order to identify areas where improvements could yield more productive mentorship. Study Design Cross-sectional survey design. Methods Residents and faculty from three otolaryngology–head and neck surgery programs were surveyed regarding their perceptions of their mentoring relationship. Trainees were asked about the characteristics of their mentorship experience. Separately, faculty were asked to describe their mentorship relationship, available resources to provide effective mentorship, and to identify areas in which formal training would improve their mentoring skills. Results Forty-eight trainees (72%) and sixty-one faculty members (73%) completed the survey. Ninety percent of residents meet with their mentors at least twice a year. Faculty and residents (> 80%) agreed that career planning was the most commonly addressed topic in mentorship sessions. However, faculty and residents differed in their perceptions of providing mentorship in other areas including clinical judgment (P = 0.003). The majority of faculty (56%) felt that formal mentorship training would improve their mentorship skills. While 95% of mentees agreed that their mentor is accessible, only 46% of faculty believed they have enough time to dedicate to mentoring (P

OBJECTIVE The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING Single-center, major university hospital. PATIENTS The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

Objectives/Hypothesis: To assess whether practice on a virtual-reality (VR) temporal bone simulator improves acquisition of technical skills in mastoid surgery. Study Design: Prospective blinded study. Methods: Using a previously validated objective structured assessment of technical skills (OSATS) tool, performance was assessed in 12 residents for two tasks of cortical mastoidectomy: 1) identifying and defining the tegmen and 2) defining the sigmoid sinus and sinodural angle. These surgical tasks were chosen as key steps in mastoid dissection because they were of intermediate complexity. Videos of virtual dissections were captured at baseline and again after practicing each task four to six times. Results: OSATS scores for the tegmen task increased from 2.125 ± 1.25 to 3.1 ± 0.85 (P = .026), whereas for the sigmoid task scores increased from 2 ± 0.45 to 2.75 ± 1.125 (P = .0098). The time to complete the tasks decreased from 8.37 ± 4.78 minutes to 5.39 ± 3.06 minutes (P = .018) for the tegmen task and from 8.99 ± 6.7 minutes to 8.68 ± 5.98 minutes (P = .594) for the sigmoid task. There was a decline in number of injuries from 0.5 ± 1.5 to 0 ± 0.5 (P = .594) for the tegmen task and from 2.5 ± 4 to 0.5 ± 1 (P = .029) for the sigmoid task. Conclusions: Technical skills in mastoidectomy surgery can be acquired during even brief practice on the VR temporal bone simulator. It is anticipated that longer periods of practice presented within the fundamentals of comprehensive curriculum will facilitate procedural learning. Further studies are required to elucidate evidence of transference of these skills to the operating room and to procedures of greater complexity.

Objectives/Hypothesis: Previous studies have identified a predominant learning style in trainees from different specialties, more recently in otolaryngology residents. The purpose of our study was to determine a predominant learning style within otolaryngology fellowships and to identify any differences between otolaryngology fellows and residents. Study Design: We conducted a survey of otolaryngology fellows at 25 otolaryngology fellowship programs accredited by the Accreditation Council for Graduate Medical Education. Methods: We emailed Kolb's Learning Style Index version 3.1 to 16 pediatric otolaryngology (PO) and 24 otology/neurotology (ON) fellows. This index is a widely used 12-item questionnaire. The participants answered each item in the questionnaire as it applied to their preferred learning style: accommodating, converging, diverging, or assimilating. Results were then analyzed and compared between each subspecialty and the previously reported preferred styles of otolaryngology residents. Results: Ten PO and 20 ON fellows completed the survey, with an overall response rate of 75%. PO and ON fellows (60% of each group) preferred a learning style that was “balanced” across all four styles. For ON fellows, 35% preferred converging and 5% preferred accommodating styles. For PO fellows, converging and accommodating styles accounted for 20% each. Conclusions: It was previously reported that 74.4% of otolaryngology residents prefer either converging or accommodating styles. We believe that the fellowship training environment calls for fellows to use more than one learning style to become proficient physicians, hence the trend toward potentially developing a balanced style when at this level.

Objectives: To develop a valid and reliable tool for an objective structured clinical examination (OSCE) on hoarseness. To pilot-test the feasibility by assessing residents' clinical skills in various core competencies while assessing hoarseness on a standardized patient (SP). Study Design: Educational tool development. Methods: The OSCE checklists were developed using modified Delphi technique after obtaining feedback from faculty involved in providing care to hoarseness patients. SP-based and rest stations were created to assess clinical skills. Twelve Otolaryngology–Head and Neck Surgery residents participated in the study. Video recordings of residents' performance and their written documentation were rated by faculty members. Results: The OSCE that we developed is a valid method of assessing residents' clinical skills for evaluating hoarseness. Senior residents performed better in all of the tasks such as obtaining history and performing a physical exam on an SP, ability to perform flexible laryngoscopy on a mannequin, and interpretation of radiologic findings. Internal consistency assessed by Cronbach's alpha as measure of inter-item reliability was 0.92 for laryngoscopic station and 0.95 for radiology station. Conclusions: This OSCE can be effectively used for the objective assessment of clinical competency in hoarseness. Our pilot study evaluated multiple competencies on a single occasion, including medical knowledge, patient care, professionalism, and communication and interpersonal skills. Clinical competence in history taking, physical examination, flexible fiber-optic laryngoscopy, and ability to interpret radiologic findings improved with increasing year of training. This OSCE provides targeted assessment of practice-based learning and feedback for improvement of clinical performance. Laryngoscope, 2010

Objectives: To evaluate the reliability and validity of the assessment tool for endoscopic sinus surgery when used in the operating room for in-training assessment of operative competency; to identify the tasks that may serve as the best indicators for overall surgical performance. Study Design: Cross-sectional validation study. Methods: We implemented the global and checklist parts of the endoscopic sinus surgery (ESS) assessment tool to evaluate the surgical skills of 13 Otolaryngology–Head & Neck Surgery residents (PGY 1–5) in the operating room over a period of 15 months. Rhinology faculty scored residents' performance of every step of ESS at the end of each procedure using a previously validated tool. Construct validity was calculated by comparing scores across training levels (using analysis of variance [ANOVA]). Regression analysis was performed to identify tasks on the ESS checklist that most strongly correlated to the overall surgical performance. Results: Construct validity was demonstrated with senior residents performing better than junior residents. Average checklist and global scores improved with the number of days on rhinology rotation. “Identification of uncinate and boundaries” was found to be the strongest predictor of overall surgical performance. Conclusions: The results indicate that this evaluation tool is a reliable and valid instrument for the assessment of surgical competency in the operating room. It can be used to identify weak areas of performance for which additional training may be required early in the rotation/training. Laryngoscope, 2010

Objectives/Hypothesis: To identify the barriers faced by otolaryngology program directors as they implement competency-based education and assessment and to identify preferred approaches to meet these challenges as suggested by program directors. Study Design: A national survey of otolaryngology–head and neck surgery program directors. Methods: We developed a 20-item questionnaire that was distributed to 102 otolaryngology program directors through SurveyMonkey. Nonrespondents were reminded by follow-up email and phone calls. Results were analyzed by descriptive statistical analysis. Results: A total of 88 (86%) program directors responded to the survey. There was a marked discrepancy between the income received and time spent performing the duties of the program director. Program director workload was recognized as the most important barrier to the implementation of competency-based education. Creating a practical clearinghouse of existing and emerging assessment tools was given the highest rating among the approaches to meet the challenges faced by program directors. Conclusions: Program directors in otolaryngology do not have sufficient financial support, protected time, and personnel to fulfill their administrative and educational responsibilities. They should be provided with additional institutional assistance to help them achieve the goals of the Accreditation Council for Graduate Medical Education outcome project.

Objectives/Hypothesis: To establish milestones toward achievement of surgical competency by using an objective assessment tool designed to measure the development of mastoidectomy skills in the operating room (OR). Study Design: Prospective longitudinal validation study. Methods: Fifty-six evaluations were conducted in the OR on nine otolaryngology residents from PGY (postgraduate year) 2 to PGY 5 over a period of 3 years. Technical performance was measured over time using a task-based checklist developed for assessment of mastoidectomy skills. Results: Three sets of technical milestones represented achievement of competency for progressively more complicated procedural steps: the first set was achieved after a mean of 6 ± 4.3 cases, the second set after 9 ± 6.7 cases (range of mean = 8–10 cases), and the third set after 13 ± 6.4 cases (range of mean = 12–14 cases). Conclusions: The acquisition of mastoidectomy skills can be integrated into surgical teaching in the OR, and this approach yields information that can aid individual skill development and program improvement. The identification of milestones in particular can help establish training benchmarks toward achievement of competency and in identifying trainees in need of remediation.

Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy.We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006).The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006).A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Objectives/Hypothesis: Kolb portrays four learning styles depending on how an individual grasps or transforms experience: accommodating, assimilating, diverging, and converging. Past studies in surgery, medicine, and anesthesia identified the predominant learning style in each of these specialties. The prevalence of different learning styles and existence of a predominant style, if any, has not been reported for otolaryngology residency programs. The purpose of our study was to determine if otolaryngology residents have a preferred learning style that is different from the predominant learning styles reported for other specialties. Study Design: We conducted a survey of the otolaryngology-head and neck surgery residents at two residency programs. Methods: Kolb's Learning Style Index (LSI) version 3.1 was administered to 46 residents from Johns Hopkins University and Kansas University Otolaryngology–Head and Neck Surgery programs. LSI is a widely used 12-item questionnaire, with each item followed by four options. The subjects graded the options depending on how the options applied to them. Results: Forty-three otolaryngology residents completed the survey, with a response rate of 93.47%. The predominant learning style was converging (55.81%) followed by accommodating (18.61%), accounting for the learning styles of 74.42% of the total population. There were only 13.95% assimilating and 6.98% diverging learning styles. Two residents (4.65%) had their preference balanced across four learning styles. Conclusions: The predominant learning styles in otolaryngology were converging and accommodating, accounting for three fourths of the population. It would be desirable to modify our curriculum in a way that will optimize and facilitate learning.

Background Otolaryngology residency programs are required by the Accreditation Council for Graduate Medical Education to evaluate residents’ operative competency. Many such tools based on the model of objective structured assessment of technical skills (OSATSs) have been developed in other surgical specialties, but no such instruments exist for otolaryngologic procedures except for tonsillectomy. Endoscopic sinus surgery (ESS) is among the most common rhinologic procedure and lends itself to objective evaluation of operative competency. The purpose of this study was to develop and test a new tool for ESS, focusing on feasibility, content and construct validity, and interrater agreement that can be used for such assessment in the operating room and the cadaver dissection course. Methods Faculty input via the modified Delphi technique helped develop the content of a new OSATS-based instrument. The instrument underwent serial improvements based on 3 years of endoscopic sinus surgery (ESS) cadaver courses. All evaluations were used to calculate construct validity while paired observations were used to determine interrater agreement. Regional and national faculty input was incorporated for increasing generalizability. Internal consistency was calculated using Cronbach's alpha. Results A total of 51 assessments were completed for 28 residents who were evaluated by 15 faculty members as they performed ESS on cadavers over a period of 3 years. A high degree of internal consistency (0.99) and feasibility was noted for the instrument, which took 7 minutes to complete. The interrater agreement improved with focused faculty development for the 3rd year of the course. Conclusion Our results and experience suggest that a feasible, reliable, and valid instrument for objective evaluation of operative competency can be developed for ESS. Further experience at other otolaryngology programs and efforts focused on faculty development will be needed to enhance faculty buy-in. The instrument can be used for formative and summative feedback as well as for identifying residents needing remediation.

Objectives/Hypothesis: 1) Assess current status of operative competency assessment and feedback among US Otolaryngology residency programs. 2) Evaluate correlations between assessment or feedback tools and remediation. Study Design: Survey of Program Directors. Methods: The survey was sent to 100 Program Directors inquiring about program size, mode of feedback, assessment tools, surgical portfolios, remediation, and number of residents requiring remediation in past 5 years. Associations between assessment questions and remediation (yes or no) were statistically assessed with the χ2 goodness-of-fit test. For more complicated analyses, multiple logistic regression models were created to assess predictors of the binary outcome of radiation. Results: Among 72 respondents, subjective evaluations are used by 95.8% (69 of 72). Formative feedback after cases is used by 38.9% (28 of 72). Summative feedback at end of the rotation is done by 57.0% (41 of 72). Objective Structured Assessments of Technical Skills is used by 15.3% (11 of 72) of programs, most are large on the basis of number of residents or faculty or both. Operative portfolios are kept by 48.6% (35 of 72) of programs. The percentage of programs with mechanisms for remediation is 41.7% (30 of 72). Similarly, of the programs who responded to the remediation question, the percentage with at least one resident requiring remediation is 37.5%. Programs who report at least one resident remediation are statistically more likely to have a remediation mechanism in place (75% vs. 27.5%; P

The techniques of performing a tracheostomy has transformed over time. Percutaneous tracheostomy is gaining popularity over open tracheostomy given its advantages and as a result the number of bedside tracheostomies has increased necessitating the need for a Percutaneous Tracheostomy Program. The Percutaneous Tracheostomy Program at the Johns Hopkins Hospital is a comprehensive service that provides care to patients before, during, and after a tracheostomy with a multidisciplinary approach aimed at decreasing complications. Education is provided to patients, families, and health-care professionals who are involved in the management of a tracheostomy. Ongoing prospective data collection serves as a tool for Quality Assurance.

Percutaneous bedside dilatational tracheotomy has become a safe alternative to open tracheotomy. Based on the widely practiced Seldinger technique, the Ciaglia procedure can be a useful addition to an otolaryngologist’s armamentarium. Adherence to a rigid protocol including considerations of contraindications, use of a team approach, and bronchoscopic guidance will ensure optimal outcome.

Competency-based surgical residency training is rapidly becoming the norm across surgical specialties. Ensuring that graduating surgeons are competent to deliver the necessary services and skills to their patients remains a seminal objective of training programs. Defining surgical competence, the measures used to assess and quantify that competence, and the criteria used to judge whether it has been achieved are critical issues. The bar that surgical residency programs have established is, and must continue to be, set very high. Definitions of competency differ across disciplines. In education, two approaches are recognized. According to the behaviorist approach, competence is assessed by precise measures of performance, generally documented by checklists. The integrated (holistic) approach defines competence as a complex combination of personal attributes. Assessments of competence also fall under two categories: the traditional scientific paradigm, emphasizing objectivity and reproducibility, and the judgment paradigm, reflecting the need to assess clinical competence in the final stages of medical training. In surgery, competence is the ability to successfully apply professional knowledge, skills, and attitudes to new situations as well as to familiar tasks. A critical step in assessing surgical competency is developing methodology for competency evaluation and certification. Matching different aspects of surgical competency with the appropriate assessment instruments is the theme of the contemporary evaluation process, with emphasis on a whole-task approach and the assessment of professional judgment. An effective assessment program will incorporate several competency elements, using multiple sources of information to assess competencies on multiple occasions, at various levels, and in different settings.

Introduction: Percutaneous dilation tracheotomy (PDT) is now an accepted alternative to surgical tracheotomy in certain patients. We began performing these procedures in 2000 and use it regularly in select intensive care unit patients requiring prolonged intubation and mechanical ventilation. Materials and Methods: A retrospective chart review of consecutive PDTs performed in the Department of Otolaryngology-Head and Neck Surgery at the John Hopkins Hospital between 2002 and 2005 was undertaken. Procedural and postoperative complications in an earlier group were compared with those in the later group for both frequency and severity. Results: Three hundred eighteen PDTs were performed on intensive care patients during this time period. All were performed using the Ciaglia method and the Cook Blue Rhino (Cook Medical Products, Bloomington, IN) set under direct bronchoscopic visualization. In group A (first 159 patients), there were a total of 12 complications (7.5%), including six cases of perioperative hemorrhage, whereas in group B (second 159 PDTs), there were seven complications (4.4%) with no cases of perioperative hemorrhage. Conclusions: PDT provides an easy and convenient alternative to open tracheotomy (OT) and should be added to the otolaryngologist's armamentarium of surgical airway procedures. The complication rate of PDT is low and similar to that of open operative tracheotomy. However, with experience and the use of strict protocols in both patient selection and PDT procedure, the complication rate can be significantly reduced further both in frequency and severity, making it even safer than an open operative tracheotomy.

Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging.We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge.Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which200 providers were trained.DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

Objectives/Hypothesis The goal of our study is to identify the number of Endoscopic Sinus Surgery (ESS) cases required to obtain competency in ESS, using a previously validated assessment tool. Study Design Prospective observational study. Methods Seventeen residents from Johns Hopkins Otolaryngology–Head & Neck Surgery residency program were evaluated as they performed endoscopic sinus surgery in the operating room. Global and checklist parts of the ESS instrument were used for assessment purposes. Items on the tool were grouped into three different milestones for analysis of data (Milestone 1 = Maxillary Antrostomy + Anterior Ethmoidectomy, Milestone 2 = Posterior Ethmoidectomy + Sphenoidostomy, Milestone 3 = Frontal Sinusotomy). Residents were deemed competent if they achieved a minimum score of 3 on a 5-point Likert scale on each step of the surgery. Results A total of 73 evaluations were completed for 17 residents (Postgraduate Level 2–5) by eight evaluators between 2009 and 2011. A 60% probability of achieving competency in performance of all milestones of ESS is obtained with performing 42 ESS procedures and the probability is increased to a 100% with performance of 55 endoscopic sinus surgery procedures. On average it took residents 23 cases to become competent in performance of maxillary antrostomy and anterior ethmoidectomy. Conclusions Our results suggest that it requires 42 ESS procedures to attain a 60% probability of competency in ESS. These results have implications for otolaryngology residency programs when developing curriculum and benchmarks for the training residents. Laryngoscope, 123:2932–2934, 2013

Introduction The Accreditation Council for Graduate Medical Education (ACGME) introduced the Outcome Project in July 2001 to improve the quality of resident education through competency-based learning. The purpose of this systematic review is to determine and explore the perceptions of program directors regarding challenges to implementing the ACGME Outcome Project. Methods We used the PubMed and Web of Science databases and bibliographies for English-language articles published between January 1, 2001, and February 17, 2012. Studies were included if they described program directors' opinions on (1) barriers encountered when attempting to implement ACGME competency-based education, and (2) assessment methods that each residency program was using to implement competency-based education. Articles meeting the inclusion criteria were screened by 2 researchers. The grading criterion was created by the authors and used to assess the quality of each study. Results The survey-based data reported the opinions of 1076 program directors. Barriers that were encountered include: (1) lack of time; (2) lack of faculty support; (3) resistance of residents to the Outcome Project; (4) insufficient funding; (5) perceived low priority for the Outcome Project; (6) inadequate salary incentive; and (7) inadequate knowledge of the competencies. Of the 6 competencies, those pertaining to patient care and medical knowledge received the most responses from program directors and were given highest priority. Conclusions The reviewed literature revealed that time and financial constraints were the most important barriers encountered when implementing the ACGME Outcome Project.

Objectives/Hypothesis This study explores the influence of selected factors on achievement of competency in mastoid surgery. Study Design A prospective study of surgical performance and a retrospective survey of learner and training factors. Methods The longitudinal performance of 15 residents was evaluated using the mastoidectomy task-based checklist (TBC). The influence of surgical experience, resident interest, and training factors (course attendance, voluntary use of simulation laboratory) was also examined and compared for the acquisition of distinct levels of technical skill difficulty (cortical mastoidectomy vs. facial recess). Results Ninety-six observations made during the first otology rotation were analyzed. Cortical mastoidectomy tasks showed positive associations with cumulated case numbers (OR 1.13, CI 1.04–1.23, P = .003) and interest in otology (OR 3.86, CI 1.21–12.27, P = .022). Facial recess tasks showed a larger positive association with interest in otology (OR 10.38, CI 2.25–47.94, P = .003), and negative association with extra time spent in laboratory practice (OR .05, CI 0.011–0.23, P = .000). Conclusions Learning trajectory for cortical mastoidectomy and facial recess may be influenced by different factors. Interest in otology, in particular, may have a moderating effect on the acquisition of more complex skills in mastoid surgery. A negative association between self-directed laboratory simulation and performance may reflect the impact of assessment-guided feedback in promoting deliberate practice. Further investigations are suggested to explore the interactions between individual trainee differences, educational models, and learning outcomes. Level of Evidence N/A. Laryngoscope, 123:3162–3167, 2013

Objectives/Hypothesis To determine the feasibility, reliability, and validity of an objective surgical assessment tool designed to measure the development of tonsillectomy skills by resident trainees in the operating room. A tonsillectomy evaluation instrument created previously serves as a basis for this tool, which incorporates many similar concepts but was optimized to maximize feasibility and reliability with simplified anchors and inclusion of global and task-specific sections. Study Design Prospective longitudinal validation study. Methods Faculty input via modified Delphi technique was used to develop a new objective structured assessment of technical skills–based instrument for tonsillectomy. The task-specific checklist (TSC) and global rating scale (GRS) measured tonsillectomy technical skills and overall surgical performance, respectively. Twenty-one otolaryngology–head and neck residents (ranging from postgraduate year 1 to 6) were evaluated for a period of 3 years by 11 faculty members. Results Eighty-three evaluations were completed showing strong correlation between both instruments (r = 0.95, P

OBJECTIVES To confirm interrater reliability using blinded evaluation of a skills-assessment instrument to assess the surgical performance of resident and fellow trainees performing pediatric direct laryngoscopy and rigid bronchoscopy in simulated models. DESIGN Prospective, paired, blinded observational validation study. SUBJECTS Paired observers from multiple institutions simultaneously evaluated residents and fellows who were performing surgery in an animal laboratory or using high-fidelity manikins. The evaluators had no previous affiliation with the residents and fellows and did not know their year of training. INTERVENTIONS One- and 2-page versions of an objective structured assessment of technical skills (OSATS) assessment instrument composed of global and a task-specific surgical items were used to evaluate surgical performance. RESULTS Fifty-two evaluations were completed by 17 attending evaluators. The instrument agreement for the 2-page assessment was 71.4% when measured as a binary variable (ie, competent vs not competent) (κ = 0.38; P = .08). Evaluation as a continuous variable revealed a 42.9% percentage agreement (κ = 0.18; P = .14). The intraclass correlation was 0.53, considered substantial/good interrater reliability (69% reliable). For the 1-page instrument, agreement was 77.4% when measured as a binary variable (κ = 0.53, P = .0015). Agreement when evaluated as a continuous measure was 71.0% (κ = 0.54, P < .001). The intraclass correlation was 0.73, considered high interrater reliability (85% reliable). CONCLUSIONS The OSATS assessment instrument is an effective tool for evaluating surgical performance among trainees with acceptable interrater reliability in a simulator setting. Reliability was good for both the 1- and 2-page OSATS checklists, and both serve as excellent tools to provide immediate formative feedback on operational competency.

To examine whether the implementation of a multidisciplinary percutaneous tracheostomy team decreases complications, improves efficiency in patient care, and reduces length of stay and cost in patients undergoing percutaneous tracheostomy.Case series with planned data collection.Urban, academic, tertiary care medical center.Patients who underwent a percutaneous tracheostomy in 2004 and 2008, before and after the formation of a multidisciplinary percutaneous tracheostomy team, were included in the study. Data for the study were retrieved from a tracheostomy database. Measured outcomes include complications, efficiency, length of stay, and cost.Complications such as airway bleeding and physiological disturbances decreased significantly in 2008 as compared with 2004. The percentage of patients who received a tracheostomy within 2 days increased from 42.3% to 92% (2004 vs 2008), showing improvement in efficiency of care. There was no significant difference between the groups in terms of infection rate, length of stay, or mortality. However, in a subanalysis, the length of stay was found to be decreased in patients whose primary diagnosis was a neurological disorder. Finally, despite the necessity of a hospital-based subsidy, the team approach yielded substantial financial benefit to the medical center.Airway bleeding, physiological disturbances, and efficiency of care improved after the institution of a multidisciplinary percutaneous tracheostomy team approach and may have a favorable impact on health care costs.

Objectives/Hypothesis: To this date the effect of the time taken to complete an evaluation on the psychometric properties of the instrument has not been reported. The goal of our study was to assess the effect of time taken to complete an evaluation on its validity. Study Design: Cross-sectional validation study. Methods: The global and checklist parts of tonsillectomy, mastoidectomy, rigid bronchoscopy, and endoscopic sinus surgery were used in the operating room by the otolaryngology faculty to evaluate the surgical skills of the residents. We categorized evaluations into two groups depending on the time taken to complete an evaluation (group A ≤6 days, group B >6 days). Construct validity was calculated for both groups by comparing the mean global and checklist scores of the residents across advancing postgraduate year levels. Results: A total of 468 evaluations, consisting of global and checklist parts, were completed for 29 residents by 32 evaluators. Mean number of days taken to complete an evaluation was 7.7 days. For all the evaluations completed within a 6-day time period, the construct validity was significant for both global and checklist parts of the four instruments. In cases of the evaluations completed after 6 days, the construct validity was significant for the tonsillectomy instrument only. Conclusions: Our results indicate that the time taken to complete an evaluation has a significant effect on the construct validity of the objective instrument. In the future, efforts should be focused on faculty development to ensure timely completion of the evaluation for a more valid assessment process. Laryngoscope, 2012

Objectives/Hypothesis: To test the validity, reliability, and feasibility of an evaluation tool designed to measure the development of trainees' surgical skills in the operating room for thyroid surgery. Study Design: Prospective validation study. Methods: A modified Delphi technique was employed to develop a new Objective Structured Assessment of Technical Skills–based instrument for thyroid surgery. During a 1-year period, 16 otolaryngology–head and neck surgery residents (ranging from postgraduate year 2 to 6) and one endocrine surgery fellow were evaluated by one faculty member obtaining a total of 94 evaluations. Performance was rated using a task-based checklist (TBC) and a global rating scale (GRS). The TBC measured trainees' thyroidectomy technical skills, and the GRS assessed their overall surgical performance. Results: Based on four clinical levels (junior, intermediate, senior, and surgical fellow) our tool demonstrated construct validity for both components of the assessment instrument, specifically for the TBC showing a mean difference of 0.9 (95% confidence interval: 0.5-1.3, P < .001) between the contiguous clinical levels senior versus intermediate. Cronbach α, a measure of internal consistency, was 0.96 for both components of the instrument. The correlation between the TBC and GRS was also high within trainee (r = 0.62, n = 94, P < .001) and across trainees (r = 0.96, n = 17, P < .001). Conclusions: Our tool proved to be a valid, reliable, and feasible instrument for assessing competency in thyroid surgery. It is effective in providing timely formative feedback during and upon the conclusion of the surgical procedure by identifying procedural tasks for which additional training is necessary. In addition, it enables longitudinal tracking of residents' surgical performance, thus ensuring their appropriate development. Laryngoscope, 122:103–109, 2012

Background: The steady rise in the number of critically ill patients in the USA has led to an increase in the need for tracheostomies in patients requiring chronic ventilatory support. There is a matched need for experienced operators to safely and efficiently perform these procedures. Objectives: We evaluated the effects on procedural outcomes and efficiency of percutaneous dilatational tracheostomy (PDT) placement in the medical intensive care unit (MICU) by the surgical team (ST) or interventional pulmonologists (IP). The IP team joined the PDT team in September 2007 and became primarily responsible for all PDT in the MICU. Methods: A retrospective analysis of prospectively collected data of patients who received PDT in the MICU by ST and IP from September 2007 to August 2010 was made. Outcomes including safety, efficacy, and procedural efficiency were compared. Results: One hundred seven patients underwent bedside PDT in the MICU during this period. Forty-three procedures (40.2%) were performed by the ST and 64 procedures (59.8%) were performed by IP. There was no statistical difference between the incidence of airway injury and infection between the two procedural groups. There were no deaths related to the performance of PDT in our series. PDT was completed within 48 h of request in 100% of IP patients and 95% of ST patients (p = 0.08). Conclusions: There were no statistical differences in PDT between the ST and IP groups when comparing complications. There was a trend towards an increased efficiency in time to PDT after consultation within the IP PDT group. Trained IP can safely and effectively perform PDT.

To validate the VOXEL-MAN TempoSurg simulator for temporal bone dissection.Prospective international study.Otolaryngology departments of 2 academic health care institutions in the United Kingdom and United States.Eighty-five subjects were recruited consisting of an experienced and referent group. Participants performed a standardized familiarization session and temporal bone dissection task. Realism, training effectiveness, and global impressions were evaluated across 21 domains using a 5-point Likert-type scale. A score of 4 was the minimum threshold for acceptability.The experienced group comprised 25 otolaryngology trainers who had performed 150 mastoid operations. The referent group comprised 60 trainees (mean otolaryngology experience of 2.9 years). Familiarization took longer in the experienced group (P = .01). User-friendliness was positively rated (mean score 4.1). Seventy percent of participants rated anatomical appearance as acceptable. Trainers rated drill ergonomics worse than did trainees (P = .01). Simulation temporal bone training scored highly (mean score 4.3). Surgical anatomy, drill navigation, and hand-eye coordination accounted for this. Trainees were more likely to recommend temporal bone simulation to a colleague than were trainers (P = .01). Transferability of skills to the operating room was undecided (mean score 3.5).Realism of the VOXEL-MAN virtual reality temporal bone simulator is suboptimal in its current version. Nonetheless, it represents a useful adjunct to existing training methods and is particularly beneficial for novice surgeons before performing cadaveric temporal bone dissection. Improvements in realism, specifically drill ergonomics and visual-spatial perception during deeper temporal bone dissection, are warranted.

The purpose of the study was to identify the predictors of short-term mortality in patients undergoing percutaneous dilatational tracheostomy (PDT).Retrospective analysis of data pertaining to adult patients who underwent PDT between July 2005 and June 2008 in an urban, academic, tertiary care medical center was done. Clinical and demographic data were analyzed for 483 patients undergoing PDT via multivariate logistic regression.Mortality data were examined at in-hospital, 14, 30, and 180 days postprocedure. Overall mortality rates were 11% at 14 days, 19% at 30 days, and 40% at 180 days. In-hospital mortality was 30%.Patients undergoing PDT have significant short-term mortality with 11% dying within 14 days and an in-hospital mortality rate of 30%. We identified an index diagnosis of ventilator-associated pneumonia and trauma to be associated with a higher survival rate, whereas older age, oncological diagnosis, cardiogenic shock, and ventricular-assist devices were associated with higher mortality. There is significant heterogeneity in both underlying diagnosis and patient outcomes, and these factors should be considered when deciding to perform this procedure and discussed with patients/family members to provide a realistic expectation of potential prognosis.

expertise when faced with difficult patients, or may find themselves wondering what their colleague would do when faced with a difficult problem. This miniseminar is designed to review advanced concepts that have more universal and practical applications for all otolaryngologists who care for rhinologic problems. In this entertaining and informative miniseminar, a panel of experts will discuss challenging cases, which demonstrate techniques and convey medical knowledge that will benefit all practitioners. The goal will be to educate practitioners on aspects of advanced care that can be applied by nearly any otolaryngologist. The tips, tricks, and pearls that will be covered will include applied allergy and immunology, infectious disease management, anatomic keys, technological advances to improve surgery, and ways to manage complications. Specific cases will include complicated allergic/inflammatory disorders, infectious problems, complicated nasal polyposis, encephaloceles, skull-base tumors, and others. Of the needs identified by the AAO membership for 2010, this miniseminar will cover infectious disease and antibiotic coverage, patient safety, and surgical techniques and demos. EDUCATIONAL OBJECTIVES: 1) Discuss methods of treating advanced allergic, immunologic, and infectious disorders in rhinology. 2) Review key sinus and skull base anatomy, and how to exploit these in surgery. 3) Discuss how new medical and technological advances are being applied to rhinology patients.

Objective(s): To determine the feasibility and validity of an objective assessment tool designed to measure the development of mastoidectomy skills by resident trainees in the operating room. Study Design: Prospective longitudinal validation study. Setting: Tertiary referral center and residency training program. Subjects: Otolaryngology residents. Main Outcome Measure: Technical performance as measured over time using Task-Based Checklist (TBC) and Global Rating Scale (GRS) developed for assessment of mastoidectomy skills. Results: Seventy pairs of evaluations were completed on 15 residents, showing strong correlation between both instruments (r = 0.93; p G 0.0001). Our instrument demonstrated construct validity for both TBC and GRS, showing higher scores with increasing surgical experience in otology. Both instruments showed high interitem reliability with Cronbach > coefficients of 0.98 and 0.95 for TBC and GRS, respectively. Regression analysis showed that thinning posterior external auditory canal ( p G 0.05) and opening antrum to deepen dissection at sinodural angle ( p G 0.05) were the strongest predictors of overall surgical performance. Conclusion: Our assessment tool is a feasible and valid method of evaluating acquisition of mastoidectomy skills in the operating room. It can be integrated into surgical teaching in the operating room and yields information for direct formative feedback. Key Words: CompetenceVEvaluationV MastoidectomyVObjective structured assessment of technical skillsVOperating roomVOtolaryngologyVSurgical education. Otol Neurotol 31:759Y765, 2010.