Efficacy of Surgical Simulation Training in a Low-Income Country

Reducing the Gap in Neurosurgical Education in LMICs: A Report of a Non-Profit Educational Program

INTRODUCTION

Central to neurosurgical care, neurosurgical education is particularly needed in low- and middle-income countries (LMICs), where opportunities for neurosurgical training are limited due to social and economic constraints and an inadequate workforce. The present paper aims (1) to evaluate the validity and usability of a cadaver-free hybrid system in the context of LMICs and (2) to report their learning needs and whether the courses meet those needs via a comprehensive survey.

METHODS

From April to November 2021, a non-profit initiative consisting of a series of innovative cadaver-free courses based on virtual and practical training was organized. This project emerged from a collaboration between the Young Neurosurgeons Forum of the World Federation of Neurological Societies (WFNS), the NIHR Global Health Research Group on Neurotrauma, and UpSurgeOn, an Italian hi-tech company specialized in simulation technologies, creator of the UpSurgeOn Box, a hyper-realistic simulator of cranial approaches fused with augmented reality. Over that period, 11 cadaver-free courses were held in LMICs using remote hands-on Box simulators.

RESULTS

One hundred sixty-eight participants completed an online survey after course completion of the course. The anatomical accuracy of simulators was overall rated high by the participant. The simulator provided a challenging but manageable learning curve, and 86% of participants found the Box to be very intuitive to use. When asked if the sequence of mental training (app), hybrid training (Augmented Reality), and manual training (the Box) was an effective method of training to fill the gap between theoretical knowledge and practice on a real patient/cadaver, 83% of participants agreed. Overall, the hands-on activities on the simulators have been satisfactory, as well as the integration between physical and digital simulation.

CONCLUSIONS

This project demonstrated that a cadaver-free hybrid (virtual/hands-on) training system could potentially participate in accelerating the learning curve of neurosurgical residents, especially in the setting of limited training possibilities such as LMICs, which were only worsened during the COVID-19 pandemic.

Simulation-Based Bypass Training and Learning Curves-Resident Experience

Introduction  Bypass surgery is a challenging operative procedure that requires surgical excellence. Achieving the skills required for vascular surgery is difficult to master in the operating room without intensive microsurgical training. Various models have been developed to provide training to young neurosurgeons and increase dexterity and patient safety. Bypass surgery requires complex microsurgical techniques. Methods  Microanastomosis training was performed on plastic tubes and chicken wings for 2 months. Each microanastomosis was evaluated by a senior author. Results  An improvement in the quality and patency of microanastomosis was observed. Conclusion  Microsurgical simulation training can contribute to the improvement of surgical skills and dexterity.

Role of Artificial Intelligence in Global Surgery: A Review of Opportunities and Challenges

Global surgery broadly refers to a rapidly expanding multidisciplinary field concerned with providing better and equitable surgical care across international health systems. Global surgery initiatives primarily focus on capacity building, advocacy, education, research, and policy development in low- and middle-income countries (LMICs). The inadequate surgical, anesthetic, and obstetric care currently contributes to 18 million preventable deaths each year. Hence, there is a growing interest in the rapid growth of artificial intelligence (AI) that provides a distinctive opportunity to enhance surgical services in LMICs. AI modalities have been used for personalizing surgical education, automating administrative tasks, and developing realistic and cost-effective simulation-training programs with provisions for people with special needs. Furthermore, AI may assist with providing insights for governance, infrastructure development, and monitoring/predicting stock take or logistics failure that can help in strengthening global surgery pillars. Numerous AI-assisted telemedicine-based platforms have allowed healthcare professionals to virtually assist in complex surgeries that may help to improve surgical accessibility across LMICs. Challenges in implementing AI technology include the misrepresentation of minority populations in the datasets leading to discriminatory bias. Human hesitancy, employment uncertainty, automation bias, and role of confounding factors need to be further studied for equitable utilization of AI. With a focused and evidence-based approach, AI could help several LMICs overcome bureaucratic inefficiency and develop more efficient surgical systems.

Comparing Skill Acquisition and Validity of Immersive Virtual Reality with Cadaver Laboratory Sessions in Training for Reverse Total Shoulder Arthroplasty

Immersive virtual reality (iVR) allows surgical trainees to practice skills without risking harm to patients or the need for cadaveric training resources. However, iVR has never been directly compared with cadaver training, the longtime gold standard for surgical skill training. We aimed to compare skill acquisition using cadaver laboratory and iVR training methods for augmented baseplate implantation during reverse total shoulder arthroplasty (rTSA).

Methods

In a randomized controlled trial, junior orthopaedic surgery residents were assigned to a 1-hour training with either iVR or a cadaveric laboratory session with shoulder specimens. Before training, all participants viewed an overview lecture and technique video demonstrating key steps of augmented baseplate implantation for rTSA. Participants were assessed by a blinded evaluator using validated competency checklists during cadaveric glenoid baseplate implantation. Continuous and categorial variables were analyzed using the 2-sample t test and Fisher exact test.

Results

Fourteen junior residents (3 incoming matched postgraduate year [PGY1], 6 PGY1s, 1 PGY2, and 4 PGY3s) were randomized to training with either iVR (n = 6) or cadaver laboratory (n = 8). There were no significant differences in demographic data, previous experience with rTSA, or previous use of iVR (p > 0.05). There were no significant difference in total Objective Structured Assessment of Technical Skill score (91.2% [15.2] vs. 93.25% [6.32], -0.1406 to 0.1823, p = 0.763), Global Rating Scale score (4.708 [0.459] vs. 4.609 [0.465], -0.647 to 0.450, p = 0.699), or time to completion (546 seconds [158] vs. 591 seconds [192], -176.3 to 266.8, p = 0.655) in cadaveric glenoid baseplate implantation. Average cost of iVR hardware and a 1-year software license was $4,900, and average cost of a single cadaver laboratory was $1,268.20 per resident.

Conclusions

Among junior orthopaedic residents, there is similar skill acquisition when training with either cadaver laboratory or iVR. Although additional research into this field is needed, iVR may provide an important and cost-effective tool in surgical education.

Clinical Relevance

Emerging simulation and iVR technology simulation in surgical training programs can increase access to effective and high-level surgical training across the globe and improve quality of care.

Current Implementation Outcomes of Digital Surgical Simulation in Low- and Middle-Income Countries: Scoping Review

BACKGROUND

Digital surgical simulation and telecommunication provides an attractive option for improving surgical skills, widening access to training, and improving patient outcomes; however, it is unclear whether sufficient simulations and telecommunications are accessible, effective, or feasible in low- and middle-income countries (LMICs).

OBJECTIVE

This study aims to determine which types of surgical simulation tools have been most widely used in LMICs, how surgical simulation technology is being implemented, and what the outcomes of these efforts have been. We also offer recommendations for the future development of digital surgical simulation implementation in LMICs.

METHODS

We searched PubMed, MEDLINE, Embase, Web of Science, Cochrane Database of Systematic Reviews, and the Central Register of Controlled Trials to look for qualitative studies in published literature discussing implementation and outcomes of surgical simulation training in LMICs. Eligible papers involved surgical trainees or practitioners who were based in LMICs. Papers that include allied health care professionals involved in task sharing were excluded. We focused specifically on digital surgical innovations and excluded flipped classroom models and 3D models. Implementation outcome had to be reported according to Proctor's taxonomy.

RESULTS

This scoping review examined the outcomes of digital surgical simulation implementation in LMICs for 7 papers. The majority of participants were medical students and residents who were identified as male. Participants rated surgical simulators and telecommunications devices highly for acceptability and usefulness, and they believed that the simulators increased their anatomical and procedural knowledge. However, limitations such as image distortion, excessive light exposure, and video stream latency were frequently reported. Depending on the product, the implementation cost varied between US $25 and US $6990. Penetration and sustainability are understudied implementation outcomes, as all papers lacked long-term monitoring of the digital surgical simulations. Most authors are from high-income countries, suggesting that innovations are being proposed without a clear understanding of how they can be incorporated into surgeons' practical training. Overall, the study indicates that digital surgical simulation is a promising tool for medical education in LMICs; however, additional research is required to address some of the limitations in order to achieve successful implementation, unless scaling efforts prove futile.

CONCLUSIONS

This study indicates that digital surgical simulation is a promising tool for medical education in LMICs, but further research is necessary to address some of the limitations and ensure successful implementation. We urge more consistent reporting and understanding of implementation of science approaches in the development of digital surgical tools, as this is the critical factor that will determine whether we are able to meet the 2030 goals for surgical training in LMICs. Sustainability of implemented digital surgical tools is a pain point that must be focused on if we are to deliver digital surgical simulation tools to the populations that demand them the most.

GlobalSurgBox: A Portable Surgical Simulator for Surgical Trainees Worldwide

OBJECTIVES

Identify barriers to surgical simulation in multiple countries across the income spectrum. Evaluate whether a novel, portable surgical simulator (GlobalSurgBox) would be valuable to surgical trainees and overcome these barriers.

DESIGN

Trainees from high-, middle-, and low-income countries were instructed on how to perform surgical skills using the GlobalSurgBox. Participants were sent an anonymized survey after 1 week to evaluate practicality and helpfulness of the trainer.

SETTING

Academic medical centers in 3 countries: USA, Kenya, and Rwanda.

PARTICIPANTS

48 medical students, 48 surgery residents, 3 medical officers, and 3 cardiothoracic surgery fellows.

RESULTS

99.0% of respondents agreed surgical simulation was an important aspect of surgical education. Despite 60.8% having access to simulation resources, only 3 of 40 (7.5%) US trainees, 2 of 12 (16.7%) of Kenyan trainees, and 1 of 10 (10.0%) Rwandan trainees used these resources routinely. 38 (95.0%) US trainees, 9 (75.0%) Kenyan trainees, and 8 (80.0%) Rwandan trainees with access to simulation resources stated there were barriers to using them. The frequently cited barriers included lack of convenient access and lack of time. After using the GlobalSurgBox, 5 (7.8%) US participants, 0 (0%) Kenyan participants, and 5 (38.5%) Rwandan participants reported lack of convenient access as a continued barrier to simulation. 52 (81.3%) US trainees, 24 (96.0%) Kenyan trainees, and 12 (92.3%) Rwandan trainees stated the GlobalSurgBox was a good facsimile of the operating room. 59 (92.2%) US trainees, 24 (96.0%) Kenyan trainees, and 13 (100%) Rwandan trainees stated the GlobalSurgBox better prepared them for clinical settings.

CONCLUSIONS

A majority of trainees across all 3 countries reported multiple barriers to simulation in their current surgical training. The GlobalSurgBox eliminates many of these barriers by providing a portable, affordable, and realistic way to practice skills needed in the operating room.

Development, outcome and costs of a simulation-based neurosurgery bootcamp at the national level

INTRODUCTION

With a growing interest in simulation-based training to develop clinical proficiency, bootcamps have been utilized for imparting basic skills to medical trainees. While considerable research on the topic exists in high income countries, no such neurosurgical teaching standards have been employed in Low- and Middle-Income Countries.

METHODS

We conducted a cross-sectional study to explore the effectiveness of first low-cost, multi-center regional neurosurgery bootcamp in South Asia. Twenty-two participants attended the bootcamp and practiced 12 hands-on skills over the course of 2 days. Burr-holes and craniotomies were done on 3D printed skulls. Lumbar drain insertion was practiced on a purpose-built lumbar puncture mannequin. For laminectomy, we used an in-house designed simulation. The modified Objective Structured Assessment of Technical Skills tool was utilized for skills Assessment. Feedback from faculty and residents was collected via a standard 5-point Likert scale.

RESULTS

Only one participant (4.55%) had previously attended a neurosurgical skills workshop. Comparison of outcomes on 1^st and 3^rd attempts of cranial and spinal skills showed a significant improvement in all 14 domains assessed (p <0.05). Positive feedback was received ranging from 3.9 up to 4.8 on a 5-point Likert scale. Overall cost per participant culminated to $145, significantly lower than previously reported data.

CONCLUSION

Our findings report the effectiveness of sustainable, low-cost training models which can be easily reproduced elsewhere. These indigenously designed simulators can be modified for variable difficulty level and serve as an effective educational strategy in improving learners' skills, knowledge and confidence.

AMPATH surgical app: Low-cost simulator for the open appendectomy

BACKGROUND

Due to a shortage and maldistribution of surgeons within Kenya, doctors with limited formal surgical training often perform emergency surgical procedures such as appendectomy. This lack of training can compromise patient outcomes and complicate care delivery. Our aim was to develop a low-cost simulator and skills curriculum to effectively teach open appendectomy.

METHODS

Surgeons from 4 countries participated in semi-structured interviews to define the steps and technique of open appendectomy using cognitive task analysis. Using this input, our Academic Model Providing Access to Healthcare surgical team developed a curriculum, including a simulator and feedback mechanism. Surgeons and surgical trainees from Kenya and the United States tested the simulator prototype and provided feedback for its refinement based on clarity, utility, and realism.

RESULTS

Instructions for a self-constructed simulator were developed at the cost of 70 Kenyan shillings (0.64 US dollars). Fifteen surgeons and surgical residents gave feedback on the simulator and curriculum, and each was presented with an updated version based on feedback. Overall, the curriculum was clear, with each sub-step receiving a median score of ≥83.5 out of 100 for clarity; however, through iterative design, the utility of sub-steps on the simulator improved.

CONCLUSION

A comprehensive open appendectomy curriculum, including a low-cost appendectomy simulator model, was developed and refined using surgeon feedback. Such curricula may benefit trainees in low-resource settings who may otherwise have limited access to quality training material.

Colorectal Surgery Practice, Training, and Research in Low-Resource Settings

Colorectal surgery (CRS) practice, training, and research differ between low- and middle-income countries (LMICs) and high-income countries due to disparity in resources. LMIC CRS is primarily done by general surgeons due to the paucity of fully trained colorectal surgeons. The majority of colon and rectal resections are done using open techniques, and laparoscopy and robotic platforms are only available in select private or academic centers. Multi-disciplinary teams are not available in most hospitals, so surgeons must have a broad knowledge base, and learn to adapt their practice. Formal CRS training opportunities through accredited post-residency fellowships and professional colorectal surgical associations are limited in LMICs. CRS is less established as an academic field, and less data are generated in LMICs. There are fewer staff and less dedicated funding for CRS research. However, LMIC colorectal surgeons and researchers can contribute valuable clinical findings especially on conditions of higher prevalence in their settings such as anal squamous cell carcinoma and obstetric fistulas. Effective surgical care for colorectal conditions requires significant investment in infrastructure, training, and governance in LMICs. This is critical to improve access to safe surgical care for all.

Development of a Modular and Equitable Surgical Simulator

Current trends in surgical simulation favor high-fidelity, costly models that are often limited to high-income academic centers. The GlobalSurgBox overcomes many of the barriers to routine implementation and use of surgical simulators in low-income countries by circumventing the often prohibitive financial, time, and personnel investments required of current simulation prototypes.

There is a tremendous need for affordable and accessible surgical simulators in the United States and abroad. Our group developed a portable, modular, inexpensive surgical simulator designed for all levels of surgical trainees, from medical students to cardiothoracic surgery fellows, and adaptable to a variety of surgical specialties. Our goal is to provide a platform for innovative surgery simulation that applies to any learner or resource setting. We describe the development, assembly, and future directions for this simulator.

The Successful Implementation of a Laparoscopic Simulation Training Program in the Dominican Republic

INTRODUCTION

Mount Sinai Hospital in New York introduced a laparoscopic surgery simulation center to a public hospital in Santiago, Dominican Republic to determine the feasibility of training programs in low-and-middle income countries (LMICs).

METHODS

In August 2018, recruitment and preliminary data were collected at the Hospital Jose Maria Cabral y Báez in Santiago, Dominican Republic. The simulation room consists of three simulation stations. Residents were required to practice 1 h/wk guided by a general surgery postgraduate year 3 (PGY3) Mount Sinai resident. Number of hours practiced was self-reported and follow-up data was collected in June 2019. The study endpoints include times on three simulated laparoscopic tasks including peg-transfer, precision cutting, and intracorporeal knot tying. Wilcoxon-signed rank tests were used for statistical analysis.

RESULTS

The partnership between hospitals allowed for successful integration into the Dominican general surgery training. Over 10 mo, residents averaged 25 h of practice (range: 8-35 h; SD 9.95 h). In total, 85% of the residents participated in the study (5 postgraduate year 1 [PGY1], 2 postgraduate year 2 [PGY2], and 4 postgraduate year 3 [PGY3]). Resident median simulation times significantly improved for precision cutting (3:49 min versus 2:09 min, P = 0.002) and intracorporeal knot tying (5:20 min versus 2:47 min, P = 0.037). There was neither significant difference in peg-transfer times nor performance between resident years (P = 0.12).

CONCLUSIONS

This study demonstrates the successful integration of a laparoscopic simulation program into an LMIC surgical resident training program. With commitment from local institutions and external resources, establishing laparoscopic simulation centers are feasible and expandable, thereby allowing general surgery residents in other LMICs, the opportunity to improve their laparoscopic skills.

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions

Background

The number of people living in fragile, conflict-affected, and vulnerable (FCV) settings is growing rapidly and attention to achieving universal health coverage must be accompanied by sufficient focus on the safety of care for universal access to be meaningful. Healthcare workers in these settings are working under extreme conditions, often with insufficient contextualized evidence to support decision-making. Recognising the relative paucity of, and methodological issues in gathering evidence from these settings, the evidence scanning described in this paper considered which patient safety interventions might offer the 'better bet', eg, the most effective and appropriate intervention in FCV settings.

Methods

An evidence scanning approach was used to examine the literature. The search was limited to FCV settings and low-income settings as defined by the World Bank, but if a systematic review included a mix of evidence from FCV/low income settings, as well as low-middle income settings, it was included. The search was conducted in English and limited to studies published from 2003 onwards, utilising Google Scholar as a publicly accessible database and further review of the grey literature, with specific attention to the outputs of non-governmental organisations. The search and subsequent analysis were completed between April and June 2020.

Results

The majority of studies identified related to strengthening infection prevention and control which was also found to be the 'better bet' intervention that could generalise to other settings, be most feasible to implement, and most effective for improving patient care and associated outcomes. Other prioritized interventions include risk management, with contributing elements such as reporting, audits, and death review processes.

Conclusions

Infection prevention and control interventions dominate in the literature for multiple reasons including strength of evidence, acceptability, feasibility, and impact on patient and health worker well-being. However, there is an urgent need to further develop the evidence base, specialist knowledge, and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions, and risk management.

Nursing students' experiences with simulation-based education as a pedagogic method in low-resource settings: A mixed-method study

AIMS AND OBJECTIVES

This study introduced simulation-based education in nurse education programs in Tanzania and Madagascar and explored nursing students' experiences with this pedagogic method as a mode of learning.

BACKGROUND

Simulation-based education has barely been introduced to education programs in resource-constrained settings. The study was conducted in two nurse education programs: one in rural Tanzania and the other in the mid-land of Madagascar. Both institutions offer diploma programs in nursing. Simulation-based education has not been included in the teaching methods used in these nursing programs.

DESIGN

A descriptive and convergent mixed method design was employed.

METHODS

Ninety-nine nursing students were included in the study. Simulation sessions followed by data collection took place once in 2017 and twice in 2018. Data were collected by means of several questionnaires and six focus groups. The data were analyzed using descriptive statistics and qualitative content analysis. The Standards for Reporting Qualitative Research (SRQR) was used to report the results.

RESULTS

The quantitative data revealed that the students rated all the questions related to the simulation design elements, educational practices, and students' satisfaction and self-confidence in learning with scores of above four on a 5-point Likert scale. The qualitative data from the first theme, building competence and confidence, further emphasized and outlined the quantitative results. Additionally, the qualitative data revealed a second theme, improving through encouragement and corrections. The students clearly expressed that they wanted to be aware of their weaknesses to be able to improve; however, the provision of feedback should be carried out in an encouraging way.

CONCLUSION

The findings indicated that the nursing students were satisfied with simulation as a pedagogic method, as it improved their competence and prepared them for professional practice. Further research is necessary to explore whether the students are able to transfer their knowledge into clinical practice.

RELEVANCE TO CLINICAL PRACTICE

Simulation as a pedagogic method is valuable for the learning of clinical skills and preparation for clinical practice.

A novel program to enhance pediatric emergency medicine training in Thailand

BACKGROUND

In Thailand, there are few pediatric emergency medicine (PEM) fellowship-trained providers, and emergency departments (EDs) are staffed by pediatricians and emergency physicians. Our pediatric ED collaborated with Thailand's largest private hospital system to develop a training program designed to improve emergency care for children.

OBJECTIVE

The objective was to develop, implement, and assess the efficacy of a curriculum to improve PEM care by emergency providers in a Thai health system.

METHODS

We conducted a prospective study from January 2018 to July 2019. After an initial needs assessment, we developed a curriculum with 22 modules, divided into basic and advanced courses. Each course began with baseline testing, consisting of written tests and several simulated cases led by physician-nurse teams. Each course was administered longitudinally through electronic modules over 6 months, with in-person shadowing and skills workshops at the course midpoint, culminating in final summative examinations and repeat simulation testing.

RESULTS

On written examination scores for the basic course, physicians (n = 5) improved by 37.6% (95% confidence interval [CI] = 29.8% to 45.4%, p < 0.001), while nurses (n = 5) improved by 55.7% (95% CI = 45.8% to 65.6%, p < 0.001). For simulation testing among physician-nurse dyads, performance improved by 19.5% (95% CI = 3.9% to 35.1%, p = 0.004) for critical action items and by 3.0 points (95% CI = 2.3 to 3.7, p < 0.001) on a 16-point teamwork scale. For the advanced course, physicians improved on the written examination by 36.9% (95% CI = 29.2% to 44.7%, p < 0.001) and nurses by 50.6 (95% CI = 47.3% to 54.0%, p < 0.001). For simulation testing, performance improved from 22.2% (95% CI = 8.2% to 35.6%, p < 0.001) for critical actions and 1.3 points (95% CI = 0.2 to 2.2, p = 0.005) on teamwork measures.

CONCLUSIONS

We designed an interdisciplinary curriculum and successfully trained Thai physicians and nurses to improve PEM knowledge and teamwork.

Laparoscopic Appendectomy Performed by Surgical Interns: Is it Too Early?

BACKGROUND

Laparoscopic appendectomy (LA) is a common procedure among surgical trainees. However, first-year residents' involvement in this procedure is scarcely studied. We aimed to determine the safety and outcomes of LA performed by surgical interns early in their first year of surgical training.

MATERIALS AND METHODS

A retrospective review of all patients who underwent LA for acute appendicitis from 2006 to 2019 was performed. All patients operated by surgical interns were included. The sample was divided into 2 groups: LA performed during the first (G1) and last 3 months (G2) of their first year of residency. Demographics, operative variables, and postoperative outcomes were compared between groups.

RESULTS

A total of 2009 LA were performed during the study period; 1647 (82%) were done by surgical interns. A total of 934 LA were performed at both ends of the year; 505 belonged to G1 and 429 to G2. Each surgical intern performed a mean of 40 LA. Demographics, complicated appendicitis rates, and presence of peritonitis were comparable between groups. Operative time was longer in G1 (G1: 61 vs. G2: 52 min, P<0.0001). Major morbidity (G1: 2.1% vs. G2: 3.4%, P=0.2), postoperative intra-abdominal abscess rates (G1: 2.8% vs. G2: 2.8%, P=0.66), median length of hospital stay (G1: 1.9 vs. G2: 1.8 d, P=0.59), and readmission rates (G1: 1.6% vs. G2: 2%, P=0.73) were similar between groups. There was no mortality in the series.

CONCLUSIONS

LA can be safely performed by supervised surgical interns early in their training. Despite a longer operative time, postoperative outcomes were favorable and similar as those achieved at the end of surgical internship.

The state of emergency medical technician education in Ghana

Objective

The National Ambulance Service (NAS) provides emergency medical services throughout Ghana and trains emergency medical technicians (EMTs) at the NAS Prehospital Emergency Care Training School (PECTS). Currently the majority of EMT training occurs primarily in a traditional didactic format. Students and faculty were interviewed to better understand their views of the current curriculum. Additionally, any barriers to integration of simulation-based learning were assessed. Following the interviews, the faculty was trained to conduct obstetric and neonatal simulations. The faculty was then observed introducing the simulations to the EMT students.

Methods

A standardized list of questions developed in consultation with an education expert was used to elicit student and faculty expression of opinion. Interviews were conducted in-person in small group settings. Training sessions were conducted in-person in large group settings.

Results

Students and faculty alike expressed pride in their work and 14/25 groups felt that teaching efforts were high. However, students verbalized concern involving their lack of rest (12/18) and the high volume of lectures per day (11/18). Both students and faculty felt limited by the lack of simulation tools (17/25), library resources (14/25), internet access (17/25), and infrastructure (20/25). All groups felt favorably towards the integration of simulation-based learning (25/25).

Conclusion

The faculty and students of PECTS support the transition from a curriculum based on traditional didactic learning to one based on simulation learning.

Simulation capacity building in rural Indian hospitals: a 1-year follow-up qualitative analysis

Introduction

The benefits of simulation-based medical training are well described. The most effective way to plant and scale simulation training in rural locations remains undescribed. We sought to plant simulation training programmes for anaesthesia emergencies in two rural Indian hospitals.

Methods

Two Indian consultant anaesthetists without experience in medical simulation underwent a 3-day course at the Boston Children’s Hospital’s (BCH) Simulator Program. They returned to their institutions and launched simulation programmes with an airway manikin and mock patient monitor. The 1-year experience was evaluated using individual, in-depth interviews of simulation facilitators. Three staff members (responsible for facilitating medical simulations over the prior year) at two rural hospitals in India were interviewed. None attended the BCH training; instead, they received on-the-job training from the BCH-trained, consultant anaesthetist colleagues.

Results

Successes included organisational adoption of simulation training with exercises 1 year after the initial BCH-training, increased interdisciplinary teamwork and improved clinical competency in managing emergencies. Barriers to effective, local implementation of simulation programmes fell into three categories: time required to run simulations, fixed and rigid roles, and variable resources. Thematic improvement requests were for standardised resources to help train simulation facilitators and demonstrate to participants a well-run simulation, in addition to context-sensitive scenarios.

Conclusion

An in-person training of simulation facilitators to promote medical simulation programmes in rural hospitals produced ongoing simulation programmes 1 year later. In order to make these programmes sustainable, however, increased investment in developing simulation facilitators is required. In particular, simulation facilitators must be prepared to formally train other simulation facilitators, too.

Improved Complex Skill Acquisition by Immersive Virtual Reality Training: A Randomized Controlled Trial

BACKGROUND

There has been limited literature on immersive virtual reality (VR) simulation in orthopaedic education. The purpose of this multicenter, blinded, randomized controlled trial was to determine the validity and efficacy of immersive VR training in orthopaedic resident education.

METHODS

Nineteen senior orthopaedic residents (resident group) and 7 consultant shoulder arthroplasty surgeons (expert group) participated in the trial comparing immersive VR with traditional learning using a technical journal article as a control. The examined task focused on achieving optimal glenoid exposure. Participants completed demographic questionnaires, knowledge tests, and a glenoid exposure on fresh-frozen cadavers while being examined by blinded shoulder arthroplasty surgeons. Training superiority was determined by the outcome measures of the Objective Structured Assessment of Technical Skills (OSATS) score, a developed laboratory metric, verbal answers, and time to task completion.

RESULTS

Immersive VR had greater realism and was superior in teaching glenoid exposure than the control (p = 0.01). The expert group outperformed the resident group on knowledge testing (p = 0.04). The immersive VR group completed the learning activity and knowledge tests significantly faster (p < 0.001) at a mean time (and standard deviation) of 11 ± 3 minutes than the control group at 20 ± 4 minutes, performing 3 to 5 VR repeats for a reduction in learning time of 570%. The immersive VR group completed the glenoid exposure significantly faster (p = 0.04) at a mean time of 14 ± 7 minutes than the control group at 21 ± 6 minutes, with superior OSATS instrument handling scores (p = 0.03). The immersive VR group scored equivalently in surprise verbal scores (p = 0.85) and written knowledge scores (p = 1.0).

CONCLUSIONS

Immersive VR demonstrated substantially improved translational technical and nontechnical skills acquisition over traditional learning in senior orthopaedic residents. Additionally, the results demonstrate the face, content, construct, and transfer validity for immersive VR.

CLINICAL RELEVANCE

This adequately powered, randomized controlled trial demonstrated how an immersive VR system can efficiently (570%) teach a complex surgical procedure and also demonstrate improved translational skill and knowledge acquisition when compared with a traditional learning method.

Treating Hand Trauma in Low-Resource Setting: A Challenge for Low- and Middle-Income Countries

Hand trauma surgical treatment and perioperative therapy are often lacking in low- and middle-income countries resulting in high rates of patient morbidity following injury. Providing education through a multifaceted approach including in-person teaching, written resources, videos, and Internet and social media platforms and facilitating skill acquisition through simulation permits local providers to gain expertise in hand trauma care and thus benefits patients. This article outlines challenges faced by low- and middle-income countries in caring for hand trauma patients and possible implementable solutions.

Teaching Hand Surgery in the Developing World: Utilizing Educational Resources in Global Health

The development of surgical capacity in the developing world is essential to address the global burden of surgical disease. Training local surgeons in low-income and middle-income countries is critical in this endeavor. The challenges to teaching hand surgery in the developing world include a shortage of local faculty, absence of a defined curriculum, no competency-based evaluation systems, few subspecialty training opportunities, and lack of financial support. To teach hand surgery in the developing world effectively, the authors suggest principles and components of a global training curriculum.

The Utility of an Open-Access Surgical Simulator to Enhance Surgeon Training

BACKGROUND

Smile Train, an international children's charity committed to improving cleft care around the world, empowers local medical professionals in developing countries to provide quality comprehensive cleft care in their own communities. As part of their sustainable model, Smile Train developed a web-based, interactive virtual simulator to improve surgical training of cleft procedures for surgeons around the world, replicating the anatomical and technical steps involved in cleft surgery. This study evaluated the simulator as a tool for enhancing surgical training.

METHODS

A pre-test and questionnaire addressing cleft care, surgical knowledge, and confidence level was administered to surgeons-in-training at an academic institution. Participants completed 3 simulator modules followed by a post-test and questionnaire to measure changes in knowledge and confidence levels.

RESULTS

Sixteen surgeons-in-training participated in this study. The mean score on the knowledge examination increased after reviewing the modules for both junior residents (33.1%-64.4%) and senior residents (46.9%-70.8%). Reviewing the modules increased participants' confidence in the knowledge of cleft anatomy, understanding of surgical procedures, and ability to follow along meaningfully while assisting in operations.

CONCLUSIONS

The Smile Train Virtual Surgery Simulator increased knowledge and reported surgeon confidence in understanding and assisting in cleft lip surgery, signifying its usefulness as a training tool for surgeons-in-training. Virtual simulation is a valuable resource for improving understanding and competence of the craniofacial surgeon while serving as an educational resource to other members of the comprehensive cleft care team, patients, and families.

A snapshot of surgical resident training in Japan: results of a national-level needs assessment survey

PURPOSE

To evaluate the status of surgical training in Japan through a national-level needs assessment.

METHODS

A survey was sent to all 909 graduating residents (GRs) and their 611 program directors (PDs) for the year 2016. A working group of surgical educators from around the country was formed under the education committee of the Japan Surgical Society. The survey items were developed by consensus of this working group. The survey investigated the knowledge and problems of the current curriculum, and the status of the current residency training.

RESULTS

The response rates were 56.3% of the GRs and 76.8% of the PDs. Among the participants, 47.6% of the GRs and 29.4% of the PDs believed that the residency curriculum did not match the clinical experience. Over 80% of the GRs and PDs agreed on the importance of training outside of the OR, whereas only 13% of the GRs had received such training regularly. Trainees also reported a lower satisfaction rate about the opportunity to train outside of the OR.

CONCLUSION

This national-level needs assessment of surgical training in Japan identified several gaps in the curriculum. These results provide valuable data to assist the ongoing efforts for surgical residency curriculum improvement.

Disseminating technology in global surgery

Background

Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.

Methods

This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.

Results

Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.

Conclusion

Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.

Affordable Laparoscopic Camera System (ALCS) Designed for Low- and Middle-Income Countries: A Feasibility Study

BACKGROUND

Minimally invasive surgical techniques (MISTs) could have tremendous benefits in resource-poor environment. There is growing interest in MISTs in most low- and middle-income countries (LMIC), but its adoption has remained limited; this is largely due to high cost of the initial setup, lack of technological backup and limited access to training among others. An affordable laparoscopic setup will go a long way in improving access to MISTs.

METHODS

A common zero degrees 10 mm scope is attached on the camera of a low-price smartphone. Two elastic bands are used to fix the scope right in front of the smartphone's main camera; alternatively, a low-cost camera coupler can be used. The device is covered with sterile transparent drapes and a light source connected with a fiber-optic cable for endoscopic use. The image can be seen in real time on a common TV screen through an HDMI connection to the smartphone, with a sterile drape.

RESULTS

We were able to perform the five tasks of the Fundamentals of Laparoscopic Surgery curriculum, using our vision system with proficiency. In a pig model, we performed a tubal ligation to simulate an appendectomy and we were able to suture. No major differences were measured between the two connection systems.

CONCLUSIONS

A low-cost laparoscopic camera system can benefit surgeons and trainees in LMICs. The system is already attractive for use during training, but further studies are needed to evaluate its potential clinical role in LMICs.

An Evaluation of the Role of Simulation Training for Teaching Surgical Skills in Sub-Saharan Africa

Background

An estimated 5 billion people worldwide lack access to any surgical care, whilst surgical conditions account for 11–30% of the global burden of disease. Maximizing the effectiveness of surgical training is imperative to improve access to safe and essential surgical care on a global scale. Innovative methods of surgical training have been used in sub-Saharan Africa to attempt to improve the efficiency of training healthcare workers in surgery. Simulation training may have an important role in up-scaling and improving the efficiency of surgical training and has been widely used in SSA. Though not intended to be a systematic review, the role of simulation for teaching surgical skills in Sub-Saharan Africa was reviewed to assess the evidence for use and outcomes.

Methods

A systematic search strategy was used to retrieve relevant studies from electronic databases PubMed, Ovid, Medline for pertinent articles published until August 2016. Studies that reported the use of simulation-based training for surgery in Africa were included.

Results

In all, 19 articles were included. A variety of innovative surgical training methods using simulation techniques were identified. Few studies reported any outcome data. Compared to the volume of surgical training initiatives that are known to take place in SSA, there is very limited good quality published evidence for the use of simulation training in this context.

Conclusions

Simulation training presents an excellent modality to enhance and improve both volume and access to high quality surgical skills training, alongside other learning domains. There is a desperate need to meticulously evaluate the appropriateness and effectiveness of simulation training in SSA, where simulation training could have a large potential beneficial impact. Training programs should attempt to assess and report learner outcomes.

Developing Trauma Audit Filters for Regional Referral Hospitals in Cameroon: Mixed-Methods Approach

BACKGROUND

Injuries are a leading cause of death and disability worldwide. Developing countries account for 90% of injury-related deaths globally. Trauma audit filters can facilitate trauma quality improvement initiatives and reduce the injury burden. Little is known about context-appropriate trauma audit filters for developing countries such as Cameroon. This study aimed to (1) develop context-appropriate trauma audit filters for the setting of a regional referral hospital in Cameroon and (2) to assess the barriers and facilitators to their implementation.

METHODS

Feasible audit filters were identified by a panel of Cameroonian surgeons using the Delphi technique. A Likert scale (1 to 5, with 5 as "Most Useful") was used to rank the filters for utility in a regional referral hospital setting, analyzed using the median and interquartile range. Semistructured interviews were conducted with 16 health care providers from three hospital facilities to explore their perceptions of supervision and support they receive from hospital administration, availability of resources, their work environment, and potential concerns and impacts of trauma audit filters. Interviews were coded and thematically analyzed.

RESULTS

Within a panel of seven surgeons, 23 of 40 trauma audit filter variables met majority consensus criteria. Twenty-one of these, comprising mostly of primary survey and basic resuscitation techniques, had a median score of ≥4. Filters meeting consensus include, but are not limited to, vitals obtained, breathing assessment made, and two large bore intravenous established within 15 min of arrival; patient with open fracture receives intravenous antimicrobials within 1 h of arrival; patients with suspected spine injury are immobilized and given X-ray. The provider interviews revealed that the barriers to providing quality care were limited human and material resources and patients' inability to pay. Regular staff training in trauma care and the belief that trauma audit filters would potentially streamline work practices and improve the quality of care were cited as promoters of successful implementation.

CONCLUSIONS

Primary survey and basic resuscitative techniques are key elements of context-appropriate audit filters in Cameroon. Such audit filters may not be costly, require complex infrastructure, or equipment that exceed the site's capabilities. Proper staff orientation and participation in the use of trauma audit filters, as quality improvement tools, are key to local buy-in and implementation success.

Creation, Implementation, and Assessment of a General Thoracic Surgery Simulation Course in Rwanda

BACKGROUND

The primary objective was to provide proof of concept of conducting thoracic surgical simulation in a low-middle income country. Secondary objectives were to accelerate general thoracic surgery skills acquisition by general surgery residents and sustain simulation surgery teaching through a website, simulation models, and teaching of local faculty.

METHODS

Five training models were created for use in a low-middle income country setting and implemented during on-site courses with Rwandan general surgery residents. A website <http://thoracicsurgeryeducation.com> was created as a supplement to the on-site teaching. All participants completed a course knowledge assessment before and after the simulation and feedback/confidence surveys. Descriptive and univariate analyses were performed on participants' responses.

RESULTS

Twenty-three participants completed the simulation course. Eight (35%) had previous training with the course models. All training levels were represented. Participants reported higher rates of meaningful confidence, defined as moderate to complete on a Likert scale, for all simulated thoracic procedures (p < 0.05). The overall mean knowledge assessment score improved from 42.5% presimulation to 78.6% postsimulation, (p < 0.0001). When stratified by procedure, the mean scores for each simulated procedure showed statistically significant improvement, except for ruptured diaphragm repair (p = 0.45).

CONCLUSIONS

General thoracic surgery simulation provides a practical, inexpensive, and expedited learning experience in settings lacking experienced faculty and fellowship training opportunities. Resident feedback showed enhanced confidence and knowledge of thoracic procedures suggesting simulation surgery could be an effective tool in expanding the resident knowledge base and preparedness for performing clinically needed thoracic procedures. Repeated skills exposure remains a challenge for achieving sustainable progress.

Implementing simulation in a nursing education programme: a case report from Tanzania

This paper presents a description of, and some reflections around, the experience of implementing simulation-based education within a nursing education programme in a low-income context. The students in the nursing education programme found the simulation sessions to be useful, motivating and a realistic learning method. Our experience may provide useful insight for other nursing education programmes in low-income contexts. It looks like a deeper knowledge about the feasibility of simulation-based education from both the teacher and student perspective is necessary.