Showing papers by "Rajesh Aggarwal published in 2017"

Simulation-trained junior residents perform better than general surgeons on advanced laparoscopic cases

Abstract: Multiple simulation training programs have demonstrated that effective transfer of skills can be attained and applied into a more complex scenario, but evidence regarding transfer to the operating room is limited. To assess junior residents trained with simulation performing an advanced laparoscopic procedure in the OR and compare results to those of general surgeons without simulation training and expert laparoscopic surgeons. Experimental study: After a validated 16-session advanced laparoscopy simulation training program, junior trainees were compared to general surgeons (GS) with no simulation training and expert bariatric surgeons (BS) in performing a stapled jejuno-jejunostomy (JJO) in the OR. Global rating scale (GRS) and specific rating scale scores, operative time and the distance traveled by both hands measured with a tracking device, were assessed. In addition, all perioperative and immediate postoperative morbidities were registered. Ten junior trainees, 12 GS and 5 BS experts were assessed performing a JJO in the OR. All trainees completed the entire JJO in the OR without any takeovers by the BS. Six (50 %) BS takeovers took place in the GS group. Trainees had significantly better results in all measured outcomes when compared to GS with considerable higher GRS median [19.5 (18.8–23.5) vs. 12 (9–13.8) p < 0.001] and lower operative time. One morbidity was registered; a patient in the trainees group was readmitted at postoperative day 10 for mechanical ileus that resolved with medical treatment. This study demonstrated transfer of advanced laparoscopic skills acquired through a simulated training program in novice surgical residents to the OR.

Engagement and learning in simulation: recommendations of the Simnovate Engaged Learning Domain Group

Abstract: Background Health professions education (HPE) is based on deliberate learning activities and clinical immersion to achieve clinical competence. Simulation is a tool that helps bridge the knowledge-to-action gap through deliberate learning. This paper considers how to optimally engage learners in simulation activities as part of HPE. Methods The Simnovate Engaged Learning Domain Group undertook 3 teleconferences to survey the current concepts regarding pervasive learning. Specific attention was paid to engagement in the learning process, with respect to fidelity, realism and emotions, and the use of narratives in HPE simulation. Results This paper found that while many types of simulation exist, the current ways to categorise the types of simulation do not sufficiently describe what a particular simulation will entail. This paper introduces a novel framework to describe simulation by deconstructing a simulation activity into 3 core characteristics (scope, modality and environment). Then, the paper discusses how engagement is at the heart of the learning process, but remained an understudied phenomenon with respect to HPE simulation. Building on the first part, a conceptual framework for engaged learning in HPE simulation was derived, with potential use across all HPE methods. Discussion The framework considers how the 3 characteristics of simulation interplay with the dimensions of fidelity (physical, conceptual and emotional), and how these can be conveyed by and articulated through beauty (as a proxy for efficiency) as coexisting factors to drive learner engagement. This framework leads to the translation of deliberately taught knowledge, skills and attitudes into clinical competence and subsequent performance.

Measuring intra-operative decision-making during laparoscopic cholecystectomy: validity evidence for a novel interactive Web-based assessment tool.

Abstract: Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries and other complications. Despite correlations between outcomes, expertise and advanced cognitive skills, current methods to evaluate these skills remain subjective, rater- and situation-dependent and non-systematic. The purpose of this study was to develop objective metrics using a Web-based platform and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy. An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from six institutions completed a 12-item assessment, developed based on a cognitive task analysis. Five items required subjects to draw their answer on the surgical field, and accuracy scores were calculated based on an algorithm derived from experts’ responses (“visual concordance test”, VCT). Test–retest reliability, internal consistency, and correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated. Questionnaires were administered to evaluate the platform’s usability, feasibility and educational value. Thirty-nine subjects (17 surgeons, 22 trainees) participated. There was high test–retest reliability (intraclass correlation coefficient = 0.95; n = 10) and internal consistency (Cronbach’s α = 0.87). The assessment demonstrated significant differences between novices, intermediates and experts in total score (p < 0.01) and VCT score (p < 0.01). There was high correlation between total case number and total score (ρ = 0.83, p < 0.01) and between total case number and VCT (ρ = 0.82, p < 0.01), and moderate to high correlations between total score and GOALS (ρ = 0.66, p = 0.05), VCT and GOALS (ρ = 0.83, p < 0.01), total score and OPRS (ρ = 0.67, p = 0.04), and VCT and OPRS (ρ = 0.78, p = 0.01). Most subjects agreed or strongly agreed that the platform and assessment was easy to use [n = 29 (78 %)], facilitates learning intra-operative decision-making [n = 28 (81 %)], and should be integrated into surgical training [n = 28 (76 %)]. This study provides preliminary validity evidence for a novel interactive platform to objectively assess decision-making during laparoscopic cholecystectomy.

Enhancing quality of medical care in low income and middle income countries through simulation-based initiatives: recommendations of the Simnovate Global Health Domain Group

Abstract: Background Quality of medical care in low income and middle income countries (LMICs) is variable, resulting in significant medical errors and adverse patient outcomes. Integration of simulation-based training and assessment may be considered to enhance quality of patient care in LMICs. The aim of this study was to consider the role of simulation in LMICs, to directly impact health professions education, measurement and assessment. Methods The Simnovate Global Health Domain Group undertook three teleconferences and a direct face-to-face meeting. A scoping review of published studies using simulation in LMICs was performed and, in addition, a detailed survey was sent to the World Directory of Medical Schools and selected known simulation centres in LMICs. Results Studies in LMICs employed low-tech manikins, standardised patients and procedural simulation methods. Low-technology manikins were the majority simulation method used in medical education (42%), and focused on knowledge and skills outcomes. Compared to HICs, the majority of studies evaluated baseline adherence to guidelines rather than focusing on improving medical knowledge through educational intervention. There were 46 respondents from the survey, representing 21 countries and 28 simulation centres. Within the 28 simulation centres, teachers and trainees were from across all healthcare professions. Discussion Broad use of simulation is low in LMICs, and the full potential of simulation-based interventions for improved quality of care has yet to be realised. The use of simulation in LMICs could be a potentially untapped area that, if increased and/or improved, could positively impact patient safety and the quality of care.

Simulation research to enhance patient safety and outcomes: recommendations of the Simnovate Patient Safety Domain Group

Abstract: This research was funded through an unrestricted donation from the Blema and Arnold Steinberg Foundation. NS's research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South London at King's College Hospital NHS Foundation Trust. NS is a member of King's Improvement Science, which is part of the NIHR CLAHRC South London and comprises a specialist team of improvement scientists and senior researchers based at King's College London. Its work is funded by King's Health Partners (Guy's and St Thomas' NHS Foundation Trust, King's College Hospital NHS Foundation Trust, King's College London and South London and Maudsley NHS Foundation Trust), Guy's and St Thomas' Charity, the Maudsley Charity and the Health Foundation. RT's research is supported by the Canadian Institutes of Health Research (CIHR) and the Canadian Foundation for Innovation (CFI).

Competency-Based Medical Education and Assessment of Training: Review of Selected National Obstetrics and Gynaecology Curricula

Abstract: There are global variations in obstetrics and gynaecology (OBGYN) training curricula, both in length and in their structure and content The ultimate goal for all residency programs is to ensure a skilled, competent physician, capable of independent practice by the end of his or her training An online search was used for nationally recognized OBGYN training curricula The curricula of Australia, Canada, the Netherlands, the United Kingdom, and the United States were individually reviewed and evaluated for their use of competency-based medical education and methods of assessment, including simulation These were also compared to the World Federation for Medical Education's Global Standards for postgraduate medical education Comparing the OBGYN curricula of these five countries led to quite similar results Even though curricula reviewed have or will be integrating competency-based medical education into their residency program, there is a need to develop adequate assessment tools, including simulation, to train competent physicians capable of independent practice Standardization of curricula leads to a decrease in the variability and an increase in the quality of training and allows for measurements and comparisons across centres Ultimately, modifications to the curricula or even consensus for an international standard, including a standardized national simulation curriculum, may potentially increase the quality and efficiency of training, which could have a direct impact on patient safety and quality of care

Development of an evidence-based training program for laparoscopic hysterectomy on a virtual reality simulator

Abstract: Substantial evidence in the scientific literature supports the use of simulation for surgical education. However, curricula lack for complex laparoscopic procedures in gynecology. The objective was to evaluate the validity of a program that reproduces key specific components of a laparoscopic hysterectomy (LH) procedure until colpotomy on a virtual reality (VR) simulator and to develop an evidence-based and stepwise training curriculum. This prospective cohort study was conducted in a Marseille teaching hospital. Forty participants were enrolled and were divided into experienced (senior surgeons who had performed more than 100 LH; n = 8), intermediate (surgical trainees who had performed 2–10 LH; n = 8) and inexperienced (n = 24) groups. Baselines were assessed on a validated basic task. Participants were tested for the LH procedure on a high-fidelity VR simulator. Validity evidence was proposed as the ability to differentiate between the three levels of experience. Inexperienced subjects performed ten repetitions for learning curve analysis. Proficiency measures were based on experienced surgeons’ performances. Outcome measures were simulator-derived metrics and Objective Structured Assessment of Technical Skills (OSATS) scores. Quantitative analysis found significant inter-group differences between experienced intermediate and inexperienced groups for time (1369, 2385 and 3370 s; p < 0.001), number of movements (2033, 3195 and 4056; p = 0.001), path length (3390, 4526 and 5749 cm; p = 0.002), idle time (357, 654 and 747 s; p = 0.001), respect for tissue (24, 40 and 84; p = 0.01) and number of bladder injuries (0.13, 0 and 4.27; p < 0.001). Learning curves plateaued at the 2nd to 6th repetition. Further qualitative analysis found significant inter-group OSATS score differences at first repetition (22, 15 and 8, respectively; p < 0.001) and second repetition (25.5, 19.5 and 14; p < 0.001). The VR program for LH accrued validity evidence and allowed the development of a training curriculum using a structured scientific methodology.

Just-in-time simulation-based training

Abstract: Simulation-based training and assessment in healthcare are now commonplace in the majority of industrialised nations. The role of standardised patients, high-fidelity and low-fidelity manikins, synthetic, animal and virtual reality platforms, and simulation suites, are accepted, and integrated into training curricula in medical and nursing schools, and residency programmes. Despite this widespread use, only a handful of studies have assessed the impact of simulation-based education on patient and health system outcomes, and these studies have their focus on procedural skills such as central line insertion or laparoscopic surgery.1 2 Furthermore, the emphasis of such studies has been on simulation-based education as a tool to impact early learners, with minimal consideration of its use for independent practitioners such as attending physicians and experienced nurses. An emerging area of simulation-based education is just-in-time training, or as it was termed by Niles et al in 2009, ‘rolling refreshers’, which comprised a portable manikin/defibrillator system to provide automated corrective feedback to optimise cardiopulmonary resuscitation (CPR) skills of paediatric intensive care unit staff.3 All of the 420 participants were independent practitioners, including nurses, physicians and respiratory therapists, with providers who undertook frequent refresher sessions (denoted as more than two per month), achieving CPR skills success three times more rapidly than those who were infrequent users of the simulation sessions. In 2013, Scholtz et al described a study for a central venous catheter (CVC) dressing change programme, …

Evaluating the role of simulation in healthcare innovation: recommendations of the Simnovate Medical Technologies Domain Group

Abstract: Background Innovation in healthcare is the practical application of new concepts, ideas, processes or technologies into clinical practice. Despite its necessity and potential to improve care in measurable ways, there are several issues related to patient safety, high costs, high failure rates and limited adoption by end-users. This mixed-method study aims to explore the role of simulation as a potential testbed for diminishing the risks, pitfalls and resources associated with development and implementation of medical innovations. Methods Subject-matter experts consisting of physicians, engineers, scientists and industry leaders participated in four semistructured teleconferences each lasting up to 2 hours each. Verbal data were transcribed verbatim, coded and categorised according to themes using grounded theory, and subsequently synthesised into a conceptual framework. Panelists were then invited to complete an online survey, ranking the (1) current use and (2) potential effectiveness of simulation-based technologies and techniques for evaluating and facilitating the product life cycle pathway. This was performed for each theme of the previously generated conceptual framework using a Likert scale of 1 (no effectiveness) to 9 (highest possible effectiveness) and then segregated according to various forms of simulation. Results Over 100 hours of data were collected and analysed. After 7 rounds of inductive data analysis, a conceptual framework of the product life cycle was developed. This framework helped to define and characterise the product development pathway. Agreement between reviewers for inclusion of items after the final round of analysis was 100%. A total of 7 themes were synthesised and categorised into 3 phases of the pathway: ‘design and development’, ‘implementation and value creation’ and ‘product launch’. Strong discrepancies were identified between the current and potential roles of simulation in each phase. Simulation was felt to have the strongest potential role for early prototyping, testing for safety and product quality and testing for product effectiveness and ergonomics. Conclusions Simulation has great potential to fulfil several unmet needs in healthcare innovation. This framework can be used to help guide innovators and channel resources appropriately. The ultimate goal is a structured, well-defined process that will result in a product development outcome that has the greatest potential to succeed.

Intraoperative Surgical Performance Measurement and Outcomes: Choose Your Tools Carefully.

Abstract: Overview Surgical outcomes exhibit variability, with convincing evidence that higher surgeon and hospital volumes, more so for complex procedures, lead to lower rates of morbidity and mortality.1 Quality metrics at the surgeon level may be based on structural factors such as case volume, processes like operative time and blood transfusion rates, or outcomes defined by morbidity, mortality, or quality of life scores. All measures have their advantages and disadvantages, which may depend on the procedure, setting, and ultimate goal of quality measurement. Volume is a proxy for expertise at the surgeon, clinical team, and hospital levels. Researchers have attempted to define underlying constructs for these relationships, such as the measurement of surgical skill in the operating room,2 variation in failure to rescue rates following surgery,3 and definition of system factors such as high nurse ratios and the presence of complex imaging facilities.4 This Viewpoint considers tools for measuring intraoperative performance with relation to surgical outcomes.

Laparoscopic Wedge Resection of Gastrojejunostomy for Weight Recidivism after Gastric Bypass

Abstract: Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a common problem. Often, this weight loss failure or regain may be due to a wide gastrojejunostomy (GJ). We evaluated the feasibility and safety of a novel approach of laparoscopic wedge resection of gastrojejunostomy (LWGJ) for a wide stoma after RYGB associated with weight recidivism. This is a single-center retrospective study of a prospectively collected database. We analyzed outcomes of patients with weight recidivism after RYGB and a documented wide GJ (>2 cm) on imaging, who underwent LWGJ between 11/2013 and 05/2016. Nine patients underwent LWGJ for dilated stomas. All patients were female with a mean ± SD age of 53 ± 7 years. Mean interval between RYGB and LWGJ was 9 ± 3 years. All cases were performed laparoscopically with no conversions. Mean operative time and hospital stay were 86 ± 9 min and 1.2 ± 0.4 days, respectively. The median(IQR) follow-up time was 14(12–18) months. During follow-up, there were no deaths, postoperative complications, or unplanned readmissions or reoperations. The mean and median(IQR) BMI before RYGB and LWGJ were 55.4 ± 8.1 kg/m2 and 56.1(47.9–61.7) and 43.4 ± 8.6 kg/m2 and 42.1(38.3–47.1), respectively. One year after LWGJ, mean and median(IQR) BMI significantly decreased to 34.9 ± 7.3 kg/m2 and 33.3(31.7–35.0) corresponding to a mean %EWL of 64.6 ± 19.9 (P 2 cm). Long-term follow-up is needed to determine the efficacy and durability of LWGJ and compare its outcomes with other endoscopic/surgical approaches for weight recidivism after RYGB with a documented wide GJ.

Surgical Performance: A Pathway to Excellence.

Abstract: T he structure, content, implementation, and outcomes of education during medical school, residency, and ongoing clinical practice have been the subject of extensive debate and discussion since the times of William Halsted and Abraham Flexner, and more recently by influential committees from the Institute of Medicine, the Macy Foundation, and the Association of American Medical Colleges. In January 2005, the American Surgical Association Blue Ribbon Committee published their report in this Journal, concerning the multiple forces for change impacting medical education. Workforce issues, medical student and resident education, work-hour restrictions, structure of training programs, research training, faculty education, and continuing professional development were cited as critical strategies at a national level, to define and implement a new surgical education system. In 2012, Lewis and Klingensmith considered ongoing concerns in general surgery residency training. Technological advances such as laparoscopic and intraluminal approaches, the impact of cross-sectional imaging on management of trauma patients, outpatient surgery for breast, gallbladder and hernia procedures, continued postresidency training in fellowships, increasing American Board of Surgery examination failure rates, and challenges for autonomy during residency were declared as negative impacts on resident training. Curriculum updates, online learning and selfassessment modules, decreased service responsibilities, pre-residency boot-camps, simulation-based training, earlier specialization tracks, and extended residency training length were considered plausible solutions to the issues at hand. At a broader level, there is a national agenda to implement competency-based medical education, underpinned by competencies, milestones, and entrustable professional activities (EPAs). It is the aspiration that this educational structure will ensure trainees are placed under regular scrutiny with regard to their performance, and more importantly, to hold residency programs accountable for outcomes of their graduates. A laudable goal, as indeed there is a defined relationship between where one undertakes residency, and clinical outcomes in independent practice. The challenge is how to translate and coalesce all aspects of medical school, residency, and fellowship education into delivery of high-quality surgical care. Ultimately, the intention is to produce physicians who have acquired and can demonstrate their clinical knowledge, the skills to question, examine, investigate, diagnose, and manage patients, and behaviors or attitudes to engage colleagues,

Laparoscopic Transgastric Resection of a Gastric Submucosal Tumor near Esophagogastric Junction with Concomitant Sleeve Gastrectomy: a Video Case Report

Abstract: Over the past two decades, there has been a significant rise in bariatric surgery. As a consequence, the prevalence of obese patients with a combined gastric pathology such as a submucosal tumor (SMT) requiring excision at the same time as bariatric surgery is higher but the management remains controversial. We report the safety and effectiveness of a simultaneous laparoscopic transgastric resection of a large gastric SMT near the esophagogastric junction (EGJ) with sleeve gastrectomy (SG). We present a video report of a 52-year-old male (BMI = 49 kg/m2) referred for bariatric surgery, who was found to have a large SMT 2 cm from the EGJ on the lesser curvature on previous gastroscopy. Using five ports placed for laparoscopic SG, the gastric SMT was localized through an anterior gastrotomy and fully excised using a linear stapler and the gastrotomy site was closed. SG was then performed over a 54Fr bougie, including the gastrotomy suture closure. Several factors play important roles in deciding the best surgical approach for patients who are candidates for bariatric surgery and have concomitant gastric SMTs. This video report describes a safe and effective technique of simultaneous transgastric resection of a lesser curvature gastric SMT near the EGJ in a patient undergoing SG.

Simulation Research in Gastrointestinal and Urologic Care-Challenges and Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases and National Institute of Biomedical Imaging and Bioengineering Workshop.

Abstract: A workshop on ''Simulation Research in Gastrointestinal and Urologic Care: Challenges and Opportunities'' was held at the National Institutes of Health in June 2016 The purpose of the workshop was to examine the extent to which simulation approaches have been used by skilled proceduralists (not trainees) caring for patients with gastrointestinal and urologic diseases The current status of research findings in the use and effectiveness of simulation applications was reviewed, and numerous knowledge gaps and research needs were identified by the faculty and the attendees The paradigm of ''deliberate practice,'' rather than mere repetition, and the value of coaching by experts was stressed by those who have adopted simulation in music and sports Models that are most useful for the adoption of simulation by expert clinicians have yet to be fully validated Initial studies on the impact of simulation on safety and error reduction have demonstrated its value in the training domain, but the role of simulation as a strategy for increased procedural safety remains uncertain in the world of the expert practitioner Although the basic requirements for experienced physicians to acquire new skills have been explored, the widespread availability of such resources is an unrealized goal, and there is a need for well-designed outcome studies to establish the role of simulation in improving the quality of health care

Debate on the cost of innovation in healthcare: is it too costly?

Abstract: This paper summarises a structured panel session regarding the cost of innovation in healthcare. The debate took place during the 2016 Simnovate Conference at McGill University. The audience, panel members and venue largely included members from academia as well as representatives from industry and organised medicine. The goal of the debate was to consider a balanced argument regarding the views of healthcare innovation and the associated costs. VJD ### Demand and cost The demand for healthcare is rising. The burden of disease is increasing. The population is ageing. We face the threat of emerging infectious diseases. We are struggling with health disparities.1 At the same time, all nations are facing the challenges in providing access, cost and quality healthcare.2 We are here today to talk about cost and to debate the various ways in which innovation may lead to an increase or a reduction of cost. Indeed, healthcare costs are extremely high and there is much concern about whether recent trends are sustainable. For instance, healthcare spending accounts for 19% of gross domestic product (GDP) in the USA and it is expected to grow another 4% this coming year. This is the basis for our debate. ### Drugs, medical devices and hospital care A JAMA study in November 2013 noted that 91% of increased healthcare costs between 2000 and 2011 were because of the increase in the price of drugs, medical devices and hospital care.3 It is argued by industry that to develop novel breakthrough therapies, they must invest in innovation which is risky and costly. By charging for these new therapies, industry can recover the losses related to high-risk research and development. In essence, industry needs to be incentivised and reimbursed for the dollars they put in the innovation, which often includes patents and other costs to protect the innovation. Consider exciting developments on the horizon, such …

Youth innovation showcase: achieving high-impact success with novel technologies

Abstract: Universities provide a dynamic environment that enables innovation in healthcare. Challenges to the delivery of healthcare are best overcome by fostering relationships that lead to solutions developed by young innovators. The Youth Innovation Showcase highlights the creative solutions of 5 young entrepreneurs as part of the Simnovate International Summit. Challenges in the process of innovation, finding balance as a young innovator, government support for student entrepreneurs, innovation and global health and how to adapt to the process of innovation are all topics covered in this summary.

Simnovate: simulation, innovation and education for better healthcare

Abstract: Simulation has already transformed medical education, and holds the power to shape modern healthcare systems, communities and populations. Simnovate is a mission, a community and a partnership of passionate, driven and game-changing individuals, who wish to see the change we can make together, in the world, right now. Four domains were defined: patient safety, medical technologies, global health and pervasive learning, with domain group experts that span healthcare simulation, outcomes research, aviation, serious gaming, patient safety, economics, machine learning, biorobotics, implementation science, global health and the visual arts. Bringing together simulation, innovation and education, for better health and care.

Reply to "Improving Surgical Ward Round Quality: Lessons From Studying Communication".

Abstract: performance should also take similar steps to ensure the effect of observer bias is minimized. Finally, the authors of the original article chose high dependency unit (HDU) as the setting for their study. Although HDU is a setting in which ward round effectiveness is imperative, it remains that many hospitals in the UK still do not have HDUs. As a result, the findings of this study are unlikely to translate well to general surgical wards. It is more applicable to consider ward round effectiveness in the standard ward setting; hence the vascular ward that we chose for our study is likely to better represent surgical ward rounds across different hospitals and the results of other studies may be more comparable to ours. Future studies should therefore take place on general surgical wards. Overall, our study highlights several important points to consider. We have found the introduction of ward round checklist, use of independent observers, and the decision to concentrate on the general surgical ward round setting are important steps in measuring and improving ward round quality on surgical ward rounds. We look forward to publishing our results following the completion of the third and final cycle and hope that future ward round studies follow a similar approach. The need to optimize surgical ward rounds is vital for the purpose of improving patient outcomes and satisfaction. We therefore look forward to seeing further literature on this topic.