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Background This project involved the development and evaluation of a new visual bleeding feedback (VBF) system for tourniquet training. We hypothesized that dynamic VBF during junctional tourniquet training would be helpful and well received by trainees. Materials and Methods We designed the VBF to simulate femoral bleeding. Medical students (n = 15) and emergency medical service (EMS) members (n = 4) were randomized in a single-blind, crossover study to the VBF or without feedback groups. Poststudy surveys assessing VBF usefulness and recommendations were conducted along with participants' reported confidence using a 7-point Likert scale. Data from the different groups were compared using Wilcoxon signed-rank and rank-sum tests. Results Participants rated the helpfulness of the VBF highly (6.53/7.00) and indicated they were very likely to recommend the VBF simulator to others (6.80/7.00). Pre- and post-VBF confidence were not statistically different (P = 0.59). Likewise, tourniquet application times for VBF and without feedback before crossover were not statistically different (P = 0.63). Although participant confidence did not change significantly from beginning to end of the study (P = 0.46), application time was significantly reduced (P = 0.001). Conclusions New tourniquet learners liked our VBF prototype and found it useful. Although confidence did not change over the course of the study for any group, application times improved. Future studies using outcomes of this study will allow us to continue VBF development as well as incorporate other quantitative measures of task performance to elucidate VBF's true benefit and help trainees achieve mastery in junctional tourniquet skills.

Medical educators have acknowledged the importance of simulation training in developing procedural skills. While simulation training in other disciplines has benefitted from evaluations of users’ skill acquisition, the majority of medical training simulators continue to be developed from overly simplified descriptions of procedures, such as techniques prescribed by existing instructional material. Our objective was to use a modeling framework to characterize the skill of various users in applying junctional tourniquets in order to design an effective training simulator. We recorded 46 medical first responders performing training exercises applying a junctional tourniquet and used coded video and sensor data to identify the hierarchy of actions they performed in the process. The model provides several insights into trainee performance, such as the way in which advanced users perform more tasks in parallel, or areas where advanced users employ situational awareness to identify ways they can deviate from recommended protocol to improve outcomes. The model successfully identifies variations in tourniquet application technique that correlates with improvement on clinically relevant metrics including application speed, pressure applied, and tourniquet placement stability. This methodology can improve medical training simulations by indicating changes during the course of learning a new task, such as helpful deviations from instructional protocol.

Background This study explores the long-term effectiveness of a newly developed clinical skills curriculum. Methods Students (N = 40) were exposed to a newly developed, simulation-based, clinical breast exam (CBE) curriculum. The same students returned one year later to perform the CBE and were compared to a convenience sample of medical students (N = 15) attending a national conferences. All students were given a clinical vignette and performed the CBE. CBE techniques were video recorded. Chi-squared tests were used to assess differences in CBE technique. Results Students exposed to a structured curriculum performed physical examination techniques more consistent with national guidelines than the random, national student sample. Structured curriculum students were more organized, likely to use two hands, a linear search pattern, and include the nipple-areolar complex during the CBE compared to national sample (p Conclusions Students exposed to a structured skills curriculum more consistently performed the CBE according to national guidelines. The variability in technique compared with the national sample of students calls for major improvements in adoption and implementation of structured skills curricula.

Background The aim of this study was to assess validity of a human factors error assessment method for evaluating resident performance during a simulated operative procedure. Methods Seven postgraduate year 4–5 residents had 30 minutes to complete a simulated laparoscopic ventral hernia (LVH) repair on day 1 of a national, advanced laparoscopic course. Faculty provided immediate feedback on operative errors and residents participated in a final product analysis of their repairs. Residents then received didactic and hands-on training regarding several advanced laparoscopic procedures during a lecture session and animate lab. On day 2, residents performed a nonequivalent LVH repair using a simulator. Three investigators reviewed and coded videos of the repairs using previously developed human error classification systems. Results Residents committed 121 total errors on day 1 compared with 146 on day 2. One of 7 residents successfully completed the LVH repair on day 1 compared with all 7 residents on day 2 ( P = .001). The majority of errors (85%) committed on day 2 were technical and occurred during the last 2 steps of the procedure. There were significant differences in error type ( P ≤ .001) and level ( P = .019) from day 1 to day 2. The proportion of omission errors decreased from day 1 (33%) to day 2 (14%). In addition, there were more technical and commission errors on day 2. Conclusion The error assessment tool was successful in categorizing performance errors, supporting known-groups validity evidence. Evaluating resident performance through error classification has great potential in facilitating our understanding of operative readiness.

The aim of this study was to evaluate validity evidence using idle time as a performance measure in open surgical skills assessment.This pilot study tested psychomotor planning skills of surgical attendings (n = 6), residents (n = 4) and medical students (n = 5) during suturing tasks of varying difficulty. Performance data were collected with a motion tracking system. Participants' hand movements were analyzed for idle time, total operative time, and path length. We hypothesized that there will be shorter idle times for more experienced individuals and on the easier tasks.A total of 365 idle periods were identified across all participants. Attendings had fewer idle periods during 3 specific procedure steps (P.001). All participants had longer idle time on friable tissue (P.005).Using an experimental model, idle time was found to correlate with experience and motor planning when operating on increasingly difficult tissue types. Further work exploring idle time as a valid psychomotor measure is warranted.

Background Recent literature has called into question resident readiness for operative independence at the end of general surgery training. Methods We used a simulation-based exit examination to assess resident readiness. Six chief residents performed 3 simulated procedures: bowel anastomosis, laparoscopic ventral hernia (LVH) repair, and pancreaticojejunostomy. Faculty assessed resident performance using task-specific checklists, Objective Structured Assessment of Technical Skills (OSATS), and final product analysis. Results Residents' individual task-specific checklist scores ranged from 25% to 100% across all 3 procedures. Mean OSATS scores ranged from 4.06 to 4.23/5.0. Residents scored significantly higher on "instrument knowledge" (mean = 4.78, standard deviation [SD] = 23) than "time and motion" (mean = 3.94, SD=.48, P = .025) and "ability to adapt to individual pathologic circumstances" (mean = 4.06, SD=.12, P = .002). Final product analysis revealed a range of errors, including incorrect technique and poor intraoperative planning. Conclusions Despite relatively high OSATS ratings, residents had a wide range of errors and procedure outcomes. Exit assessments using multiple evaluation metrics may improve awareness of residents' learning needs.

Hemorrhages are the leading cause of potentially survivable combat mortalities when patients are unable to reach a treatment facility in time. New tourniquet devices have been developed to combat hemorrhages in the field. However, there is a lack in training systems to properly teach and assess users on tourniquet device application. We have developed an objective feedback system applicable to various full body manikins. We tested the system with expert users and received improvement feedback and verified the system's usefulness in instructing and assessing correct tourniquet device use.

Background Prior work using simulation for assessing intubation skills has largely focused on the use of observer-generated performance measures in the form of checklists and global ratings scales. Purpose The purpose of our work was to investigate whether patient-centered simulation data could be used to quantify learner's performance during direct laryngoscopy. Methods We designed a pretest/posttest prospective intervention study of residents' ( n = 25) intubation skills. Results When assessing validity, all of the patient-centered simulation variables showed significant correlations with the previously validated observer-generated performance measures (r = 0.331–0.463, P ≤ 0.001). When assessing reliability, there were significant correlations between all of the sensor variables, confirming moderate to high inter-item reliability (r = 0.259–0.794, P ≤ 0.05). The observer-generated performance measures showed significant improvement in use of the Macintosh blade (T1 = 2.10/5.00, T2 = 3.64/5.00, P = 0.001). However, this was not the case for the Miller blade (T1 = 1.30/5.00, T2 = 1.75/5.00, P = 0.119). Overall, the patient-centered simulation variables provided a high level of detail regarding performance improvement areas. Conclusion This study presents a multilevel analysis of sensor-generated simulation data. As the sensors provide sound, formative data regarding patient contact, the outputs may be used for specific criterion measures and detailed performance feedback.

Objective: This study investigates using marker-less video tracking to evaluate hands-on clinical skills during simulated clinical breast examinations (CBEs). Background: There are currently no standardized and widely accepted CBE screening techniques. Methods: Experienced physicians attending a national conference conducted simulated CBEs presenting different pathologies with distinct tumorous lesions. Single hand exam motion was recorded and analyzed using marker-less video tracking. Four kinematic measures were developed to describe temporal (time pressing and time searching) and spatial (area covered and distance explored) patterns. Results: Mean differences between time pressing, area covered, and distance explored varied across the simulated lesions. Exams were objectively categorized as either sporadic, localized, thorough, or efficient for both temporal and spatial categories based on spatiotemporal characteristics. The majority of trials were temporally or spatially thorough (78% and 91%), exhibiting proportionally greater time pressing and time searching (temporally thorough) and greater area probed with greater distance explored (spatially thorough). More efficient exams exhibited proportionally more time pressing with less time searching (temporally efficient) and greater area probed with less distance explored (spatially efficient). Just two (5.9 %) of the trials exhibited both high temporal and spatial efficiency. Conclusions: Marker-less video tracking was used to discriminate different examination techniques and measure when an exam changes from general searching to specific probing. The majority of participants exhibited more thorough than efficient patterns. Application: Marker-less video kinematic tracking may be useful for quantifying clinical skills for training and assessment.

To the Editor: Clinical-skills assessments provide motivation and direction for learning.1,2 Adoption of simulation-based education methods has introduced a wide variety of options for clinical-performance assessment.3,4 To explore the potential value added by integrating sensor technology with a skills assessment, this study investigated whether sensor data could inform previously accepted observation-based performance recommendations for the clinical breast examination (CBE).5 We hypothesized that sensor technology would help to characterize successful and unsuccessful CBE techniques at a level of detail that is not possible with observation alone. The study protocol was administered in 2013 and 2014 and required practicing physicians . . .

Background The aim of our study was to modify our previously developed laparoscopic ventral hernia (LVH) simulator to increase difficulty and then reassess validity and feasibility for using the simulator in a newly developed simulation-based continuing medical education course. Methods Participants (N = 30) were practicing surgeons who signed up for a hands-on postgraduate laparoscopic hernia course. An LVH simulator, with prior validity evidence, was modified for the course to increase difficulty. Participants completed 1 of the 3 variations in hernia anatomy: incarcerated omentum, incarcerated bowel, and diffuse adhesions. During the procedure, course faculty and peer observers rated surgeon performance using Global Operative Assessment of Laparoscopic Skills–Incisional Hernia and Global Operative Assessment of Laparoscopic Skills rating scales with prior validity evidence. Rating scale reliability was reassessed for internal consistency. Peer and faculty raters' scores were compared. In addition, quality and completeness of the hernia repairs were rated. Results Internal consistency on the general skills performance (peer α = .96, faculty α = .94) and procedure-specific performance (peer α = .91, faculty α = .88) scores were high. Peers were more lenient than faculty raters on all LVH items in both the procedure-specific skills and general skills ratings. Overall, participants scored poorly on the quality and completeness of their hernia repairs (mean = 3.90/16, standard deviation = 2.72), suggesting a mismatch between course attendees and hernia difficulty and identifying a learning need. Conclusions Simulation-based continuing medical education courses provide hands-on experiences that can positively affect clinical practice. Although our data appear to show a significant mismatch between clinical skill and simulator difficulty, these findings also underscore significant learning needs in the surgical community.

This study investigates the potential of using marker-less video tracking for evaluating hands-on clinical skills. Experienced family practitioners attending a national conference were recruited and asked to conduct a breast examination on a simulator that presents different clinical pathologies. Videos were taken of the clinician’s hands during the exam. Video processing software for tracking and quantifying hand motion kinematics was used. Videos were divided into two segments: a general search segment and a mass exploration segment. The general exploration segments exhibited motion patterns which included 72% faster movement and 73% higher acceleration across clinical pathologies. The most complex pathology exhibited 14% greater displacement for pressing/rubbing than for general exploration. Marker-less video kinematic tracking shows promise in discriminating between different examination procedures, clinicians, and pathologies.

The primary purpose is to track the amount of indoor advertisement viewer using the Kinect Xbox 360 as the tracking device, and visual studio 2012 to modified the system. Using the source code named Pupillary Distance to get the drawing of eye-models, then modified it to create angle algorithm and determine ID as the viewer. There are some scenario which is to supervise the system's result with any help of volunteers to move past the camera. The scenario is to get the accuracy rate of the system. Then adding angle between the camera and the eyes to tell the position of the eyes, and to tell on what angles do a person mostly mistaken as a viewer. The benefit of the mistaken angle can be useful to get better result in the future research.

The clinical pelvic exam is a critical examination for external and internal inspection of female reproductive organs. A sensor enabled pelvic examination simulator was developed to provide immediate visual performance feedback. The simulator was modified for rural area usage, where electricity supply and PC display may not be available. We succeeded at replacing key components while maintaining functionality.

The thyroid exam is an important clinical skill that is widely practiced by both primary care and specialty physicians. Despite this, there are few teaching models that allow for practice and assessment of proper examination technique. We developed a sensorized thyroid exam model and accompanying survey to capture clinical decision making and hands-on performance. Two endocrinologists performed the thyroid exam on the models. There was verbal consensus on clinical findings; however estimates on thyroid properties and size differed. Additional experiments with an ultrasound provided feedback on use of the model for hands-on and ultrasound-based examinations.

The clinical breast examination is a critical exam for early detection of breast cancer. Assessment methods are needed to determine competency and skill mastery for experts and novices. The 3D sensor was developed to capture hand shear and normal forces conducted during an exam. Trials were conducted to record exploratory maneuvers used during the exam. The sensor system was found to be a reliable method for capturing exploratory maneuvers.

Junctional and inguinal bleeding is a significant and challenging problem on the battlefield. Inventors have developed new types of tourniquets, including the Abdominal Aortic Tourniquet™ (AAT) and the Combat Ready Clamp™ (CRoC) to address these abdominal and pelvic injuries. While these hemorrhage control technologies have been developed, validated, and approved for use, training systems that teach and refresh skills related to these technologies have not been developed. These training systems are vital because these skills can be difficult to train and are infrequently used. To address these needs, a sensor-enabled manikin was designed. Using the sensor data, the different phases of applying the tourniquet were captured and key performance was measured.

The clinical breast examination (CBE) is performed to detect breast pathology. However, little is known regarding clinical technique and how it relates to diagnostic accuracy. We sought to quantify breast examination search patterns and hand utilization with a new data collection and analysis system. Participants performed the CBE while the sensor mapping and video camera system collected performance data. From this data, algorithms were developed that measured the number of hands used during the exam and active examination time. This system is a feasible and reliable method to collect new information on CBE techniques.

The purpose of this article was to conduct a gap analysis of important team constructs that may be absent in widely used team assessments.Two assessment tools with known validity evidence (1) Non-Technical Skills for Surgeons (NOTSS) and (2) the Cannon-Bowers Scale were used to evaluate 11 teams of surgical residents (n = 33) performing simulated laparoscopic hernia repairs. Faculty raters' scores were used to compare the surveys and assess validity and reliability. Raters' detailed observation notes were used to indicate important behavioral constructs that were missing from the team rating scales.When assessing inter-item correlations (reliability) four of five NOTSS' scale items had significant correlations (r = 0.9-1.0, P 0.05) with the Cannon-Bowers items. While the correlations were only noted for three of six Cannon-Bowers items, in each instance the same four of five NOTSS items correlated with the three Cannon-Bowers items, thus providing further validity evidence for both scales. When evaluating the gap, key emerging themes included the need to focus on critical team errors, individual team member contributions, task performance, and overall team performance. These gaps, plus items from the NOTSS and Cannon-Bowers scales, were incorporated into a new rating scale.Despite continued evidence of validity and reliability, there were several behavioral constructs that were not represented when using the NOTSS and Cannon-Bowers scales. Critical team errors, individual team member contributions, task performance, and overall team performance appear important in our ability to understand teams and teamwork.

Quantification and evaluation of palpation is a growing field of research in medicine and engineering. A newly developed tri-axial touch sensor has been designed to capture a multi-dimensional profile of touch-loaded forces. We have developed a data visualization tool as a first step in simplifying interpretation of touch for assessing hands-on clinical performance.

In prior studies, mannequin-based simulation training has been used to help decrease student anxiety toward intimate clinical examinations. Using time away as an independent variable, the aim of this study was to assess decay of clinical confidence for four procedural tasks that vary in procedural complexity. Clinical confidence with intimate examinations, after a standardized mannequin-based simulation curriculum, decays over time. This decay is noted after two months of time away. Longer periods of time away did not show increased differences.

Conventional disinfection and sterilization methods are often ineffective with biofilms, which are ubiquitous, hard-to-destroy microbial communities embedded in a matrix mostly composed of exopolysaccharides. The use of gas-discharge plasmas represents an alternative method, since plasmas contain a mixture of charged particles, chemically reactive species and UV radiation, whose decontamination potential for free-living, planktonic micro-organisms is well established. In this study, biofilms were produced using Chromobacterium violaceum, a Gram-negative bacterium present in soil and water and used in this study as a model organism. Biofilms were subjected to an atmospheric pressure plasma jet for different exposure times. Our results show that 99.6 % of culturable cells are inactivated after a 5 min treatment. The survivor curve shows double-slope kinetics with a rapid initial decline in c.f.u. ml−1 followed by a much slower decline with D values that are longer than those for the inactivation of planktonic organisms, suggesting a more complex inactivation mechanism for biofilms. DNA and ATP determinations together with atomic force microscopy and fluorescence microscopy show that non-culturable cells are still alive after short plasma exposure times. These results indicate the potential of plasma for biofilm inactivation and suggest that cells go through a sequential set of physiological and morphological changes before inactivation.