SUPPLEMENT
Simulation in Pediatric Orthopaedic Surgery Donald S. Bae, MD
Abstract: Surgical simulation has become an increasingly important means of improving skills acquisition, optimizing clinical outcomes, and promoting patient safety. While there have been great strides in other industries and other fields of medicine, simulation training is in its relative infancy within pediatric orthopaedics. Nonetheless, simulation has the potential to be an important component of Quality-Safety-Value Initiative of the Pediatric Orthopaedic Society of North America (POSNA). The purpose of this article will be to review some definitions and concepts related to simulation, to discuss how simulation is beneficial both for trainee education as well as value-based health care, and to provide an update on current initiatives within pediatric orthopaedic surgery. Key Words: surgical simulation, education, pediatric orthopaedics (J Pediatr Orthop 2015;35:S26–S29)
I
n their book entitled “Fundamentals of Surgical Simulation,” Gallagher and O’Sullivan1 define simulation as “the imitation of some real thing, state of affairs, or process.” They further note a number of characteristic elements featured in any simulation. First, all simulations seek to capture relevant characteristics or behaviors of the physical object, state, or process that is being simulated. Furthermore, all simulations are constructed using simplifying approximations and assumptions. These characteristics in turn determine the fidelity—or “realness”—of the simulation. Finally, all simulations should inherently have some measurement of outcome or assessment of performance. These essential elements can be seen in any simulation, ranging from a hand-held video game to the most sophisticated aerospace simulator. While most orthopaedic educators and learners think of high-fidelity virtual reality training tools when simulation is discussed, it is important to remember that simpler, lower fidelity training exercises—from suture practice on an animal limb to fracture fixation on synthetic bone models—also encompass these critical characteristics, and in so doing, may be equally effective and impactful.
From the Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. The author declares no conflicts of interest. Reprints: Donald S. Bae, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail. [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
S26 | www.pedorthopaedics.com
THE “NEED” FOR SIMULATION Simulation has been effectively used for decades in a number of fields, most notably in the aviation industry, where flight simulation has been standardized and required, both for technical skill and crisis resource management.2,3 While simulation training in medicine, and orthopaedic surgery in particular, is relatively new, there are a host of factors that are now driving the demand for improved simulated learning. There is an increasing expectation of improved performance, patient safety, and fiscal responsibility. Indeed, the opportunity to use simulation training is highlighted by the 1999 Institute of Medicine report, “To Err is Human: Building a Safer Health System.”4 In this oft cited report by the independent, nonprofit arm of the National Academy of Sciences, 44,000 to 98,000 preventable deaths were cited to occur in US hospitals each year. In other similar reports by Brennan et al5 and Leape et al,6 adverse events were noted to occur in 3.7% of hospital admissions, of which over a quarter were due to negligence. While negligence is not the same as preventable error, these studies also determined that technical performance errors were the most common cause of injury. Surgical simulation may provide a means for improving performance and decreasing the incidence of technical errors. Furthermore, we live in an era of changing opportunities. The art and science of orthopaedic surgery is evolving at a rapid rate, in part to advances in technology and operative techniques. This is particularly true in the realm of minimally invasive and arthroscopic surgery. A number of studies have demonstrated that simulation may improve performance and decrease time to proficiency in these rapidly changing realms of orthopaedic surgery. For example, Pollard et al7 previously randomized orthopaedic surgery trainees to simulated hip arthroscopy in both supine and lateral positions. These residents demonstrated measurable improvements in performance with simulation training, and junior trainees achieved a level of performance equal to their more experienced, senior residents by the end of the 4-week study period. Studies such as this highlight the utility of simulation in arthroscopic surgical skills acquisition. In addition, surgical simulation may provide novel opportunities to address changing requirements. The advent of the trainee duty-hours restrictions, for example, has spurred tremendous discussion regarding how best to provide orthopaedic surgery trainees with the practical experience needed to achieve competence and proficiency.8 In an example provided by Dr J. Lawrence Marsh at the 2013 AAOS Orthopaedic Surgery Simu-
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
lation Summit, if the average orthopaedic surgery resident performs 2000 operations with an average length of 2 hours per case, the surgical trainee would accumulate 4000 hours of surgical experience upon completion of residency training.9 This experience pales in comparison with the 10,000 hours of cumulative experience noted by Ericsson et al10 in their famous treatise on expert performance. Simulation may provide another vehicle for deliberate practice during residency training, adding to the cumulative experience of orthopaedic learners and thus ultimately improving performance. Simulation may also serve as a convenient and standardized means of assessing resident performance, which may help to satisfy ACGME Milestones requirements. However, perhaps most importantly, simulation training is ideal for surgical education. From years of cumulative research, it is apparent that adults best learn independently, in an experience-based and problem-focused manner.11 As cited above, performance is enhanced with iterative, deliberate practice.10,12 Furthermore, behavior is better changed with double-loop, rather than single-loop, feedback, which occurs when learners understand not only “what to do” but “why.”13 Indeed, the merits of simulation with regards to adult learning may be best illustrated using Kolb’s experiential learning model14 (Fig. 1). According to Kolb’s model, after any life experience, adults will reflect upon the nature and critical elements of their experience. This reflection leads in turn to conceptualization and formation of ideas regarding how and why those experiences contained the qualities they did. Ultimately, these ever-changing conceptualizations will result in experimentation, or changes in future behavior. The process repeats itself, as new experiences are gained, further reflection occurs, and conceptualizations are modified and refined. For example, after in situ screw fixation of a moderate unstable slipped capital femoral epiphysis, a surgeon may critically evaluate a postoperative clinical and
A
radiographic result. Observations and reflections on hip range of motion, osteonecrosis, chondrolysis, and arthrosis may lead to conceptualizations regarding femoral acetabular impingement, slipped capital femoral epiphysis stability, femoral head vascularity, and implant placement. These conceptualizations may in turn lead to surgical innovations, such as alterations in patient positioning, alternative techniques of capsular decompression or surgical dislocation, and newer implant design and placement. Simulation affords learners similar opportunities to experience, reflect, conceptualize, and experiment, yet does so on demand, without patient risk, and with the opportunity for iterative and summative feedback.
HOW DOES SIMULATION ADD QUALITY, SAFETY, AND VALUE? Surgical simulation may influence the “value equation” in favorable and compelling ways (Fig. 2). First, there is ample evidence that increasing surgical case volume and providing opportunities for simulated practice improves performance and thus improves outcomes. In the general surgery literature, for example, Ahlberg et al15 demonstrated that surgical trainees randomized to virtual reality laparoscopic training were 58% faster and committed 3 times fewer errors in their first 10 laparoscopic cholecystectomies. These findings have been corroborated by other general surgical investigators as well.16–18 In orthopaedics, Howells et al19 have similarly demonstrated that residents randomized to virtual reality or dry-knee arthroscopy simulation have decreased time to proficiency and improved Global Rating Scores when performing arthroscopy on patients. Butler et al20 similarly demonstrated improved performance and transfer of skills from dry-knee arthroscopy models to cadaveric knee assessments. Even the use of Internet-based, e-learning curriculae may improve performance. Hearty et al,21 for example, randomized orthopaedic trainees to
B
Experience
Experimentation
Simulation in Pediatric Orthopaedic Surgery
Reflection
Change in practice
Postop result
Change in practice
Clinical outcomes, reasons why (AVN, FAI, chondrolysis)
Conceptualization
C
SCFE pinning
Simulation
On demand Without patient risk Accelerates learning
Debriefing
Solutions & responses
FIGURE 1. A, Schematic representation of Kolb’s learning model. B, Learning model applied to surgical treatment of slipped capital femoral epiphysis (SCFE). C, Application of learning model to surgical simulation. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
S27
J Pediatr Orthop
Bae
A
Outcome Value
= Cost
Greater volume + improved performance
B
improved outcomes
Outcome Value
= Cost
Improved efficiency, fewer complications
decreased cost
FIGURE 2. A, Simulation may increase experience and improve outcomes, thereby improving value. B, Similarly, simulation may improve efficiency and reduce complications, thereby reducing cost and increasing value.
e-learning or standardized curriculae and found higher test scores, greater comfort, and lower anxiety levels, and improved preparation and performance in those who received addition e-learning. Through these low-fidelity and high-fidelity simulation activities, value is increased by improving performance and outcomes. On the other side of the equation, simulation may improve efficiency and decrease complications, thus driving down costs and improving value delivery. Clearly the “costs” of unexpected or adverse outcomes are great, both to patients/families as well as to the health care system. Eappen et al22 recently performed a retrospective analysis of inpatient surgical discharges at 12 Southern US hospitals. Of 34,256 discharges, 1820 patients had reported complications for a rate of 5.3%. Patients with complications had $1749 to $39,017 higher hospital contribution margins, depending upon the type of insurance. While the initiation of simulation efforts may be resource intensive, the benefits may be great in the long term. In 1 compelling example from Cohen et al,23 the implementation of a medical intensive care unit simulation on central line placement cost $112,000 per year. However, by preventing 9 catheter-based bloodstream infections—with approximately $82,000 of incremental costs and 14 additional hospital days per infection—the net savings realized was approximately $700,000, representing a 7:1 return on simulation investment. These data are also helping to align all health care stakeholders, as the opportunities to increase value are becoming more and more apparent. Arriaga et al,24 for example, describe an insurer-sponsored program in which medical personnel are compensated to participate in simulation training through malpractice insurance discounts. In addition to the financial incentives, participating surgeons, nurses, and anesthesiologists found the simulations relevant and beneficial, particularly in the teamwork and communication domains. In these ways, simulation may reduce costs and increase value-based health care delivery.
S28 | www.pedorthopaedics.com
Volume 35, Number 5 Supplement 1, July/August 2015
WHAT IS HAPPENING IN PEDIATRIC ORTHOPAEDIC SURGERY? While still in its infancy, simulation is growing in pediatric orthopaedics. First and foremost, there has been an increasing awareness regarding the opportunities to improve care, patients’ safety, and value through simulation. The American Academy of Orthopaedic Surgeons (AAOS) has hosted 2 “Surgical Simulation Summits,” at which representatives from Pediatric Orthopaedic Society of North America (POSNA), the AAOS, the American Board of Orthopaedic Surgeons, and other orthopaedic specialty societies discussed the growing need and role of simulation in orthopaedic education.25 POSNA has also assumed a leadership role in these efforts to raise awareness and develop simulation curriculae. In 2012, POSNA sponsored a surgical simulation “competition” at the annual International Pediatric Orthopaedic Symposium (IPOS) (Fig. 3).26 Dubbed “Top Gun” in reference to the 1986 movie about naval pilot training at the famed Fighter Weapons School in Miramar, CA, this program invited 30 residents and fellows to participate in a number of surgical skills stations related to pediatric orthopaedics, ranging from cast application to pedicle screw insertion to arthroscopic knot tying. Participants were graded by IPOS faculty, points were awarded, and recognition given to the top scorers. In addition to providing a platform to highlight the merits of orthopaedic simulation, the IPOS “Top Gun” program provided a novel model for orthopaedic skills education, promoted one-on-one teaching and skills feedback, and fostered collaboration among learners, educators, and industry partners. Now in its third year, “Top Gun” has become a signature program at the annual IPOS meeting. There are also many ongoing individual, institutional, and society efforts within pediatric orthopaedics. A number of investigators have worked to develop simulation models and assessment tools for pediatric orthopaedic skills and conditions, ranging from cast application and removal to pedicle screw insertion to limb deformity correction.21,27–29 Through innovative research and programmatic initiatives,
FIGURE 3. Participants tie arthroscopic knots during the 2013 IPOS “Top Gun” program. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
improved simulation tools and curriculae may become more readily available in the near future. In addition, under the auspices of the POSNA Quality-Safety-Value Initiative, a multicenter workgroup has been created to develop simulation “toolkits” consisting of didactic material, simulation models, assessment tools, and research protocols, for hopeful distribution to all pediatric orthopaedic educators and providers. This Simulation in Pediatric Orthopaedics Taskforce (SPORT) will focus its initial efforts on distal radius fractures, septic arthritis of the hip, and supracondylar humerus fractures.
SUMMARY There is an increasing need for surgical simulation training, in part due to rising expectations, emerging opportunities, and changing requirements. Perhaps more compelling, however, is the ability of simulation training to optimize adult learning and improve value in health care delivery. Through initiatives such as the IPOS “Top Gun” program and the SPORT collaborative, it is our hope that simulation training will continue to grow within pediatric orthopaedics, improving the safe and effective care of children with musculoskeletal conditions. REFERENCES 1. Gallagher AG, O’Sullivan GC. Fundamentals of Surgical Simulation: Principles and Practice. London: Springer-Verlag; 2012. 2. Helmreich RL. Managing human error in aviation. Sci Am. 1997; 276:62–67. 3. Leedom D, Dimon R. Improving team coordination: a case for behavior-based training. Mil Psych. 1995;7:109–122. 4. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000:196–197. 5. Brennan TA, Hebert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA. 1991;265:3265–3269. 6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study. N Engl J Med. 1991;324:377–384. 7. Pollard TCB, Khan T, Price AJ, et al. Simulated hip arthroscopy skills: learning curves with the lateral and supine patient positions. J Bone Joint Surg Am. 2012;94:e68(1-10). 8. Purcell Jackson G, Tarpley JL. How long does it take to train a surgeon? BMJ. 2009;339:1062–1064. 9. Marsh JL. Surgical skills training in orthopaedic surgery residences. Presented at the 2013 Orthopaedic Surgery Simulation Summit II, November 22, 2013, Rosemont, IL. 10. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363–406. 11. Knowles MS. Andragogy, not pedagogy. Adult Leadership. 1968;16: 350–352. 386.
Copyright
r
Simulation in Pediatric Orthopaedic Surgery
12. Scho¨n D. The Reflective Practitioner, How Professionals Think In Action. New York: Basic Books; 1983. 13. Argyris C, Scho¨n D. Organization Learning: A Theory of Action Perspective. Reading, MA: Addison Wesley; 1978. 14. Kolb. DA, Fry R. Toward an applied theory of experiential learning. In: Cooper C, ed. Theories of Group Process. London: John Wiley; 1975. 15. Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Am J Surg. 2007;193:797–804. 16. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236:458–463. 17. Sroka G, Feldman LS, Vassilou MC, et al. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial. Am J Surg. 2010;199:115–120. 18. Nagendran M, Gurusamy KS, Aggarwal R, et al. Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database Syst Rev. 2013;8:CD006575. 19. Howells NR, Gill HS, Carr AJ, et al. Transferring simulated arthroscopic skills to the operating theatre: a randomized blinded study. J Bone Joint Surg Br. 2008;90:494–499. 20. Butler A, Olson T, Koehler R, et al. Do the skills acquired by novice surgeons using anatomic dry models transfer effectively to the task of diagnostic knee arthroscopy performed on cadaveric specimens? Bone Joint Surg Am. 2013;95:e15(1-8). 21. Hearty T, Maizels M, Pring M, et al. Orthopaedic resident preparedness for closed reduction and pinning of pediatric supracondylar fractures is improved by e-learning: a multisite randomized controlled study. J Bone Joint Surg Am. 2013;95: e1261–e1267. 22. Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309:1599–1606. 23. Cohen ER, Feinglass J, Barsuk JH, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010;5:98–102. 24. Arriaga AF, Gawande AA, Raemer DB, et al. Harvard Surgical Safety Collaborative. Pilot testing of a model for insurer-driven, largescale multicenter simulation training for operating room teams. Ann Surg. 2014;259:403–410. 25. Pedowitz RA, Marsh JL. Motor skills training in orthopaedic surgery: a paradigm shift toward a simulation-based educational curriculum. J Am Acad Orthop Surg. 2012;20:407–409. 26. Flynn JD. IPOS sponsors surgical simulation competition. AAOS Now, 2013. Available at: http://www.aaos.org/news/aaosnow/mar13/ youraaos9.asp. 27. Kim E, Moritomo H, Murase T, et al. Three-dimensional analysis of acute plastic bowing deformity of ulna in radial head dislocation or radial shaft fracture using a computerized simulation system. J Shoulder Elbow Surg. 2012;21:1644–1650. 28. Moktar J, Popkin CA, Howard A, et al. Development of a cast application simulator and evaluation of objective measures of performance. J Bone Joint Surg Am. 2014;96:e76. 29. Leung R, Zeller R, Walker K, et al. Towards the development of a haptic simulator of surgical gestures in orthopaedic spine surgery. Stud Health Technol Inform. 2013;184:254–260.
2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
S29
Simulation in Pediatric Orthopaedic Surgery Donald S. Bae, MD
Abstract: Surgical simulation has become an increasingly important means of improving skills acquisition, optimizing clinical outcomes, and promoting patient safety. While there have been great strides in other industries and other fields of medicine, simulation training is in its relative infancy within pediatric orthopaedics. Nonetheless, simulation has the potential to be an important component of Quality-Safety-Value Initiative of the Pediatric Orthopaedic Society of North America (POSNA). The purpose of this article will be to review some definitions and concepts related to simulation, to discuss how simulation is beneficial both for trainee education as well as value-based health care, and to provide an update on current initiatives within pediatric orthopaedic surgery. Key Words: surgical simulation, education, pediatric orthopaedics (J Pediatr Orthop 2015;35:S26–S29)
I
n their book entitled “Fundamentals of Surgical Simulation,” Gallagher and O’Sullivan1 define simulation as “the imitation of some real thing, state of affairs, or process.” They further note a number of characteristic elements featured in any simulation. First, all simulations seek to capture relevant characteristics or behaviors of the physical object, state, or process that is being simulated. Furthermore, all simulations are constructed using simplifying approximations and assumptions. These characteristics in turn determine the fidelity—or “realness”—of the simulation. Finally, all simulations should inherently have some measurement of outcome or assessment of performance. These essential elements can be seen in any simulation, ranging from a hand-held video game to the most sophisticated aerospace simulator. While most orthopaedic educators and learners think of high-fidelity virtual reality training tools when simulation is discussed, it is important to remember that simpler, lower fidelity training exercises—from suture practice on an animal limb to fracture fixation on synthetic bone models—also encompass these critical characteristics, and in so doing, may be equally effective and impactful.
From the Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA. The author declares no conflicts of interest. Reprints: Donald S. Bae, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail. [email protected]. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
S26 | www.pedorthopaedics.com
THE “NEED” FOR SIMULATION Simulation has been effectively used for decades in a number of fields, most notably in the aviation industry, where flight simulation has been standardized and required, both for technical skill and crisis resource management.2,3 While simulation training in medicine, and orthopaedic surgery in particular, is relatively new, there are a host of factors that are now driving the demand for improved simulated learning. There is an increasing expectation of improved performance, patient safety, and fiscal responsibility. Indeed, the opportunity to use simulation training is highlighted by the 1999 Institute of Medicine report, “To Err is Human: Building a Safer Health System.”4 In this oft cited report by the independent, nonprofit arm of the National Academy of Sciences, 44,000 to 98,000 preventable deaths were cited to occur in US hospitals each year. In other similar reports by Brennan et al5 and Leape et al,6 adverse events were noted to occur in 3.7% of hospital admissions, of which over a quarter were due to negligence. While negligence is not the same as preventable error, these studies also determined that technical performance errors were the most common cause of injury. Surgical simulation may provide a means for improving performance and decreasing the incidence of technical errors. Furthermore, we live in an era of changing opportunities. The art and science of orthopaedic surgery is evolving at a rapid rate, in part to advances in technology and operative techniques. This is particularly true in the realm of minimally invasive and arthroscopic surgery. A number of studies have demonstrated that simulation may improve performance and decrease time to proficiency in these rapidly changing realms of orthopaedic surgery. For example, Pollard et al7 previously randomized orthopaedic surgery trainees to simulated hip arthroscopy in both supine and lateral positions. These residents demonstrated measurable improvements in performance with simulation training, and junior trainees achieved a level of performance equal to their more experienced, senior residents by the end of the 4-week study period. Studies such as this highlight the utility of simulation in arthroscopic surgical skills acquisition. In addition, surgical simulation may provide novel opportunities to address changing requirements. The advent of the trainee duty-hours restrictions, for example, has spurred tremendous discussion regarding how best to provide orthopaedic surgery trainees with the practical experience needed to achieve competence and proficiency.8 In an example provided by Dr J. Lawrence Marsh at the 2013 AAOS Orthopaedic Surgery Simu-
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
lation Summit, if the average orthopaedic surgery resident performs 2000 operations with an average length of 2 hours per case, the surgical trainee would accumulate 4000 hours of surgical experience upon completion of residency training.9 This experience pales in comparison with the 10,000 hours of cumulative experience noted by Ericsson et al10 in their famous treatise on expert performance. Simulation may provide another vehicle for deliberate practice during residency training, adding to the cumulative experience of orthopaedic learners and thus ultimately improving performance. Simulation may also serve as a convenient and standardized means of assessing resident performance, which may help to satisfy ACGME Milestones requirements. However, perhaps most importantly, simulation training is ideal for surgical education. From years of cumulative research, it is apparent that adults best learn independently, in an experience-based and problem-focused manner.11 As cited above, performance is enhanced with iterative, deliberate practice.10,12 Furthermore, behavior is better changed with double-loop, rather than single-loop, feedback, which occurs when learners understand not only “what to do” but “why.”13 Indeed, the merits of simulation with regards to adult learning may be best illustrated using Kolb’s experiential learning model14 (Fig. 1). According to Kolb’s model, after any life experience, adults will reflect upon the nature and critical elements of their experience. This reflection leads in turn to conceptualization and formation of ideas regarding how and why those experiences contained the qualities they did. Ultimately, these ever-changing conceptualizations will result in experimentation, or changes in future behavior. The process repeats itself, as new experiences are gained, further reflection occurs, and conceptualizations are modified and refined. For example, after in situ screw fixation of a moderate unstable slipped capital femoral epiphysis, a surgeon may critically evaluate a postoperative clinical and
A
radiographic result. Observations and reflections on hip range of motion, osteonecrosis, chondrolysis, and arthrosis may lead to conceptualizations regarding femoral acetabular impingement, slipped capital femoral epiphysis stability, femoral head vascularity, and implant placement. These conceptualizations may in turn lead to surgical innovations, such as alterations in patient positioning, alternative techniques of capsular decompression or surgical dislocation, and newer implant design and placement. Simulation affords learners similar opportunities to experience, reflect, conceptualize, and experiment, yet does so on demand, without patient risk, and with the opportunity for iterative and summative feedback.
HOW DOES SIMULATION ADD QUALITY, SAFETY, AND VALUE? Surgical simulation may influence the “value equation” in favorable and compelling ways (Fig. 2). First, there is ample evidence that increasing surgical case volume and providing opportunities for simulated practice improves performance and thus improves outcomes. In the general surgery literature, for example, Ahlberg et al15 demonstrated that surgical trainees randomized to virtual reality laparoscopic training were 58% faster and committed 3 times fewer errors in their first 10 laparoscopic cholecystectomies. These findings have been corroborated by other general surgical investigators as well.16–18 In orthopaedics, Howells et al19 have similarly demonstrated that residents randomized to virtual reality or dry-knee arthroscopy simulation have decreased time to proficiency and improved Global Rating Scores when performing arthroscopy on patients. Butler et al20 similarly demonstrated improved performance and transfer of skills from dry-knee arthroscopy models to cadaveric knee assessments. Even the use of Internet-based, e-learning curriculae may improve performance. Hearty et al,21 for example, randomized orthopaedic trainees to
B
Experience
Experimentation
Simulation in Pediatric Orthopaedic Surgery
Reflection
Change in practice
Postop result
Change in practice
Clinical outcomes, reasons why (AVN, FAI, chondrolysis)
Conceptualization
C
SCFE pinning
Simulation
On demand Without patient risk Accelerates learning
Debriefing
Solutions & responses
FIGURE 1. A, Schematic representation of Kolb’s learning model. B, Learning model applied to surgical treatment of slipped capital femoral epiphysis (SCFE). C, Application of learning model to surgical simulation. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.pedorthopaedics.com |
S27
J Pediatr Orthop
Bae
A
Outcome Value
= Cost
Greater volume + improved performance
B
improved outcomes
Outcome Value
= Cost
Improved efficiency, fewer complications
decreased cost
FIGURE 2. A, Simulation may increase experience and improve outcomes, thereby improving value. B, Similarly, simulation may improve efficiency and reduce complications, thereby reducing cost and increasing value.
e-learning or standardized curriculae and found higher test scores, greater comfort, and lower anxiety levels, and improved preparation and performance in those who received addition e-learning. Through these low-fidelity and high-fidelity simulation activities, value is increased by improving performance and outcomes. On the other side of the equation, simulation may improve efficiency and decrease complications, thus driving down costs and improving value delivery. Clearly the “costs” of unexpected or adverse outcomes are great, both to patients/families as well as to the health care system. Eappen et al22 recently performed a retrospective analysis of inpatient surgical discharges at 12 Southern US hospitals. Of 34,256 discharges, 1820 patients had reported complications for a rate of 5.3%. Patients with complications had $1749 to $39,017 higher hospital contribution margins, depending upon the type of insurance. While the initiation of simulation efforts may be resource intensive, the benefits may be great in the long term. In 1 compelling example from Cohen et al,23 the implementation of a medical intensive care unit simulation on central line placement cost $112,000 per year. However, by preventing 9 catheter-based bloodstream infections—with approximately $82,000 of incremental costs and 14 additional hospital days per infection—the net savings realized was approximately $700,000, representing a 7:1 return on simulation investment. These data are also helping to align all health care stakeholders, as the opportunities to increase value are becoming more and more apparent. Arriaga et al,24 for example, describe an insurer-sponsored program in which medical personnel are compensated to participate in simulation training through malpractice insurance discounts. In addition to the financial incentives, participating surgeons, nurses, and anesthesiologists found the simulations relevant and beneficial, particularly in the teamwork and communication domains. In these ways, simulation may reduce costs and increase value-based health care delivery.
S28 | www.pedorthopaedics.com
Volume 35, Number 5 Supplement 1, July/August 2015
WHAT IS HAPPENING IN PEDIATRIC ORTHOPAEDIC SURGERY? While still in its infancy, simulation is growing in pediatric orthopaedics. First and foremost, there has been an increasing awareness regarding the opportunities to improve care, patients’ safety, and value through simulation. The American Academy of Orthopaedic Surgeons (AAOS) has hosted 2 “Surgical Simulation Summits,” at which representatives from Pediatric Orthopaedic Society of North America (POSNA), the AAOS, the American Board of Orthopaedic Surgeons, and other orthopaedic specialty societies discussed the growing need and role of simulation in orthopaedic education.25 POSNA has also assumed a leadership role in these efforts to raise awareness and develop simulation curriculae. In 2012, POSNA sponsored a surgical simulation “competition” at the annual International Pediatric Orthopaedic Symposium (IPOS) (Fig. 3).26 Dubbed “Top Gun” in reference to the 1986 movie about naval pilot training at the famed Fighter Weapons School in Miramar, CA, this program invited 30 residents and fellows to participate in a number of surgical skills stations related to pediatric orthopaedics, ranging from cast application to pedicle screw insertion to arthroscopic knot tying. Participants were graded by IPOS faculty, points were awarded, and recognition given to the top scorers. In addition to providing a platform to highlight the merits of orthopaedic simulation, the IPOS “Top Gun” program provided a novel model for orthopaedic skills education, promoted one-on-one teaching and skills feedback, and fostered collaboration among learners, educators, and industry partners. Now in its third year, “Top Gun” has become a signature program at the annual IPOS meeting. There are also many ongoing individual, institutional, and society efforts within pediatric orthopaedics. A number of investigators have worked to develop simulation models and assessment tools for pediatric orthopaedic skills and conditions, ranging from cast application and removal to pedicle screw insertion to limb deformity correction.21,27–29 Through innovative research and programmatic initiatives,
FIGURE 3. Participants tie arthroscopic knots during the 2013 IPOS “Top Gun” program. Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Pediatr Orthop
Volume 35, Number 5 Supplement 1, July/August 2015
improved simulation tools and curriculae may become more readily available in the near future. In addition, under the auspices of the POSNA Quality-Safety-Value Initiative, a multicenter workgroup has been created to develop simulation “toolkits” consisting of didactic material, simulation models, assessment tools, and research protocols, for hopeful distribution to all pediatric orthopaedic educators and providers. This Simulation in Pediatric Orthopaedics Taskforce (SPORT) will focus its initial efforts on distal radius fractures, septic arthritis of the hip, and supracondylar humerus fractures.
SUMMARY There is an increasing need for surgical simulation training, in part due to rising expectations, emerging opportunities, and changing requirements. Perhaps more compelling, however, is the ability of simulation training to optimize adult learning and improve value in health care delivery. Through initiatives such as the IPOS “Top Gun” program and the SPORT collaborative, it is our hope that simulation training will continue to grow within pediatric orthopaedics, improving the safe and effective care of children with musculoskeletal conditions. REFERENCES 1. Gallagher AG, O’Sullivan GC. Fundamentals of Surgical Simulation: Principles and Practice. London: Springer-Verlag; 2012. 2. Helmreich RL. Managing human error in aviation. Sci Am. 1997; 276:62–67. 3. Leedom D, Dimon R. Improving team coordination: a case for behavior-based training. Mil Psych. 1995;7:109–122. 4. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000:196–197. 5. Brennan TA, Hebert LE, Laird NM, et al. Hospital characteristics associated with adverse events and substandard care. JAMA. 1991;265:3265–3269. 6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study. N Engl J Med. 1991;324:377–384. 7. Pollard TCB, Khan T, Price AJ, et al. Simulated hip arthroscopy skills: learning curves with the lateral and supine patient positions. J Bone Joint Surg Am. 2012;94:e68(1-10). 8. Purcell Jackson G, Tarpley JL. How long does it take to train a surgeon? BMJ. 2009;339:1062–1064. 9. Marsh JL. Surgical skills training in orthopaedic surgery residences. Presented at the 2013 Orthopaedic Surgery Simulation Summit II, November 22, 2013, Rosemont, IL. 10. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100:363–406. 11. Knowles MS. Andragogy, not pedagogy. Adult Leadership. 1968;16: 350–352. 386.
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