Mental skills training limits the decay in operative technical skill under stressful conditions: Results of a multisite, randomized controlled study.

BACKGROUND: Overwhelming stress in the operating room can lead to decay in operative performance, particularly for residents who lack experience. Mental skills training can minimize deterioration in performance during challenging situations. We hypothesized that residents trained on mental skills would outperform controls under increased stress conditions in the simulated operating room. METHODS: Residents from Indiana University enrolled voluntarily in this institutional review board-approved study. Residents were stratified according to baseline characteristics and randomized into a mental skills and control group. Both groups trained to proficiency in laparoscopic suturing, but only the mental skills group received mental skills training. After training, technical skill transfer was assessed under regular and stressful conditions on a porcine model. Performance was assessed using an objective suturing score. The Test of Performance Strategies was used to assess the use of mental skills. Data were combined and compared with data that had been collected at Carolinas Healthcare System because residents underwent the same protocol. RESULTS: A total of 38 residents completed all study elements. There were no differences in the effects observed between sites. We observed no group differences at baseline. The groups achieved similar technical performance at baseline, posttest, and transfer test under low-stress conditions, but the mental skills group outperformed the control group during the transfer test under high-stress conditions. CONCLUSION: Our comprehensive mental skills curriculum implemented with surgery residents at two institutions was effective at minimizing the deterioration of resident technical performance under stressful conditions compared with controls. These results provide further evidence for the effectiveness of mental skills training to optimize surgery trainees' technical performance during challenging clinical situations.

Patient satisfaction and cosmetic outcome in a randomized study of cesarean skin closure.

Objective: To evaluate patient satisfaction and patient and physician assessment of scar appearance after cesarean skin closure with suture versus staples. Methods: Women undergoing cesarean delivery (CD) at ≥23 weeks' gestation via low-transverse skin incisions at three hospitals in the CROSS Consortium were randomized to receive skin closure using subcuticular absorbable suture or nonabsorbable metal staples. The primary outcome of this substudy, patient satisfaction, was assessed by surveys at the postpartum visit using a 10-point Likert scale. Scar outcomes according to patients and trained observers were assessed at the primary research site using the Patient and Observer Scar Assessment Scale (POSAS). The POSAS is comprised of a patient-completed assessment including subjective data such as pain and itchiness, and an observer-completed assessment about cosmetic criteria. Results: Between June 2010 and August 2012, 746 women were randomized; 370 received suture and 376 received staples. Satisfaction data were available for 606 (81%). Complete patient scar assessment data were available for 577 (77%) and complete observer scar assessment data were available for 275 (57% of the 480 planned for evaluation at the primary research site). Demographic data for women in the two groups were similar. Satisfaction with the closure method was higher (superior) among women who received suture closure: median 10 (interquartile range 9, 10) versus 9 (interquartile ranges (IQR) 6, 10); p < .01. The suture group also had higher satisfaction with the scar's appearance at the postpartum visit: median nine (IQR 7, 10) versus 8 (IQR 6, 10); p = .02. Receiving one's preferred closure method was associated with higher patient satisfaction, and wound complications were associated with lower satisfaction. POSAS scores were superior (lower) in the suture group. Patient Scar Assessment Scale scores were median 15 (IQR 10, 25) for sutures versus 20 (IQR 11, 28) for staples; p < .01. Observer Scar Assessment Scale scores were median 12 (IQR 9, 15) for sutures versus 13 (IQR 9, 16) for staples; p = .01. Conclusions: Satisfaction with the closure method, satisfaction with the scar's appearance, and patient and physician assessments of scar cosmesis were all superior in those closed with suture. These results further support the use of sutures for cesarean skin closure.

Certified Child Life Specialists Lessen Emotional Distress of Children Undergoing Laceration Repair in the Emergency Department.

OBJECTIVE: The objective of this study is to evaluate the impact of certified child life specialists (CCLSs) on the emotional responses of children undergoing laceration repair in the emergency department (ED). METHODS: Patients 4 to 12 years of age who required laceration repair by suturing were prospectively enrolled at an urban tertiary pediatric ED. Certified child life specialists are not available at all times in our institution, allowing for a priori categorization of subjects into 2 comparison groups, those with and those without CCLS involvement. Subjects requiring anxiolysis, pharmacologic sedation, narcotics, or physical restraint were excluded. The Children's Emotional Manifestation Scale, a previously validated Likert-like tool, was used to quantify the patients' distress, with a higher score reflecting a more emotional child. Just before placement of the first suture, subjects were scored by trained independent observers. Baseline data included age, sex, race, type of local anesthetic, length and location of laceration, and analgesics administered. The primary endpoint of emotional score was compared with a 2-tailed Mann-Whitney U test, with a P < 0.05 considered statistically significant. RESULTS: Two hundred one patients constituted the final study cohort, with 103 (51%) having CCLS involvement. Study groups did not differ in regards to any baseline demographic or clinical characteristics. The median emotional score for patients with child life services was 7 (interquartile range, 6-9) versus 9 (interquartile range, 7.5-12) for those without (P < 0.0005). CONCLUSIONS: Certified child life specialist involvement is associated with less emotional distress for children undergoing laceration repair in the ED.

Temporal Stress in the Operating Room: Brain Engagement Promotes "Coping" and Disengagement Prompts "Choking".

OBJECTIVE: To investigate the impact of time pressure (TP) on prefrontal activation and technical performance in surgical residents during a laparoscopic suturing task. BACKGROUND: Neural mechanisms enabling surgeons to maintain performance and cope with operative stressors are unclear. The prefrontal cortex (PFC) is implicated due to its role in attention, concentration, and performance monitoring. METHODS: A total of 33 residents [Postgraduate Year (PGY)1-2 = 15, PGY3-4 = 8, and PGY5 = 10] performed a laparoscopic suturing task under "self-paced" (SP) and "TP" conditions (TP = maximum 2 minutes per knot). Subjective workload was quantified using the Surgical Task Load Index. PFC activation was inferred using optical neuroimaging. Technical skill was assessed using progression scores (au), error scores (mm), leak volumes (mL), and knot tensile strengths (N). RESULTS: TP led to greater perceived workload amongst all residents (mean Surgical Task Load Index score ±â€ŠSD: PGY1-2: SP = 160.3 ±â€Š24.8 vs TP = 202.1 ±â€Š45.4, P < 0.001; PGY3-4: SP = 123.0 ±â€Š52.0 vs TP = 172.5 ±â€Š43.1, P < 0.01; PGY5: SP = 105.8 ±â€Š55.3 vs TP = 159.1 ±â€Š63.1, P < 0.05). Amongst PGY1-2 and PGY3-4, deterioration in task progression, error scores and knot tensile strength (P < 0.05), and diminished PFC activation was observed under TP. In PGY5, TP resulted in inferior task progression and error scores (P < 0.05), but preservation of knot tensile strength. Furthermore, PGY5 exhibited less attenuation of PFC activation under TP, and greater activation than either PGY1-2 or PGY3-4 under both experimental conditions (P < 0.05). CONCLUSIONS: Senior residents cope better with temporal demands and exhibit greater technical performance stability under pressure, possibly due to sustained PFC activation and greater task engagement. Future work should seek to develop training strategies that recruit prefrontal resources, enhance task engagement, and improve performance under pressure.

Mental skills training effectively minimizes operative performance deterioration under stressful conditions: Results of a randomized controlled study.

BACKGROUND: Stress can negatively impact surgical performance, but mental skills may help. We hypothesized that a comprehensive mental skills curriculum (MSC) would minimize resident performance deterioration under stress. METHODS: Twenty-four residents were stratified then randomized to receive mental skills and FLS training (MSC group), or only FLS training (control group). Laparoscopic suturing skill was assessed on a live porcine model with and without external stressors. Outcomes were compared with t-tests. RESULTS: Twenty-three residents completed the study. The groups were similar at baseline. There were no differences in suturing at posttest or transfer test under normal conditions. Both groups experienced significantly decreased performance when stress was applied, but the MSC group significantly outperformed controls under stress. CONCLUSIONS: This MSC enabled residents to perform significantly better than controls in the simulated OR under unexpected stressful conditions. These findings support the use of psychological skills as an integral part of a surgical resident training.

Effect of Face-to-Face Education on Anxiety and Pain in Children with Minor Extremity Injuries Undergoing Outpatient Suturing in Emergency Department.

OBJECTIVE: To assess the effect of face-to-face education on anxiety and pain in children with minor extremity injuries undergoing outpatient suturing. METHODS: Children in intervention and control groups received face-to-face education (10 minutes) and no specific education, respectively. The anxiety and pain was measured using Modified-Yale Preoperative Anxiety Scale, and pain by Faces Pain Scale-Revised, respectively in 3 stages viz, pre-procedure and pre-intervention, post-procedure. RESULTS: Children in the intervention group were less anxious than the control at pre-procedure and post-intervention stage (41.1 (13.8) vs. 46.3 (19.1), respectively, P=0.03) and post-procedure and post-intervention stage (32.3 (17.2) vs. 40.2 (12.9), respectively, P=0.01). Children in the intervention group experienced less pain than the control at pre-procedure and post-intervention stage (3.9 (3.8) vs. 4.9 (3.1), respectively, P<0.001) and post-procedure and post-intervention stage (3.1 (1.2) vs. 4.0 (2.1), respectively, P=0.001). CONCLUSION: Face-to-face education could reduce anxiety and pain in children undergoing suturing in the emergency department.

Transseptal Suturing Reduce Patient Anxiety after Septoplasty Compared to Nasal Packing.

BACKGROUND: We measured postoperative anxiety in patients who underwent transseptal suturing or nasal packing after septoplasty. MATERIALS AND METHODS: Transseptal suturing was performed on Group 1 patients and nasal splints with airway were placed after septoplasty in Group 2 patients. Postoperative 48-h anxiety levels of both groups were measured using the State-Trait Anxiety Inventory (STAI) clinical assessment scale, prior to removal of nasal packing in Group 2. RESULTS: Transseptal suturing was performed after septoplasty in 28 patients and nasal packing in 34 patients. The State-Trait Anxiety Inventory clinical assessment state (STAI-S) and trait (STAI-T) instruments were used to measure postoperative anxiety. The STAI-S scores were found 35.00 in the transseptal suturing group and 43.8 in the nasal packing group; the difference was found significant (p < 0.05). The STAI-T scores were found 42.6 in the transseptal suturing group and 45.7 in the nasal packing group; the difference was not found significant (p > 0.05). The rate of minor hemorrhage was found 10.7% in Group 1 patients. CONCLUSIONS: Transseptal suturing is simple and reliable when performed after septoplasty. The technique is painless and comfortable, and reduces patient anxiety (compared to that associated with nasal packing) with only a minor increase in operating time and hemorrhage.

Cesarean skin closure preferences: a survey of obstetricians.

OBJECTIVE: In light of the limited evidence directing cesarean skin closure techniques, we evaluated the factors guiding obstetricians' preferences for closure method. METHODS: From 07/11 to 12/11, an online survey was sent to obstetricians in ACOG Regions I and II. Obstetricians were asked to indicate their cesarean skin closure preferences when considering various factors and to rank the importance of these factors in their decision. Practice type, experience and usual method of closure were also assessed. RESULTS: Responses were received from 470 of 1400 surveyed (34% response rate), of which 422 were analyzed. Similar proportions reported primarily using sutures (39%) or staples (48%); 13% use both methods equally. More obstetricians at community hospitals primarily use sutures (48% versus 39%, p < 0.001), while more at university hospitals primarily use staples (57% versus 30%, p < 0.001). Listed in decreasing order of importance, sutures were preferred when considering patient satisfaction, keloid susceptibility, cosmesis, first Pfannenstiel incisions or cost. Staples were preferred when considering wound infections, obese patients, chorioamnionitis, HIV/AIDS or busy labor floors (p < 0.001). CONCLUSION: The limited evidence to guide cesarean skin closure forces obstetricians to rely on personal experience. Our survey indicates that despite this limitation, obstetricians have specific preferences for cesarean skin closure method.

Measuring mental workload during the performance of advanced laparoscopic tasks.

INTRODUCTION: Mental workload is a finite resource and is increased while learning new tasks and performing complex tasks. Measurement of a surgeon's mental workload may therefore be an indication of expertise. We hypothesized that surgeons who were expert at laparoscopic suturing would have more spare mental resources to perform a secondary task, compared with surgeons who had just started to learn suturing. METHODS: Standardized suturing tasks were performed on a bench-top model. Twelve junior residents (novices) and nine fellows and attending surgeons (experts) were instructed to perform as many sutures as possible in 6 min. An adjacent monitor was placed 15 degrees off axis to the first and randomly displayed 30 true visual signals among 90 false ones. Participants were required to identify the true signals while continuing to suture. Laparoscopic sutures were evaluated using the Fundamentals of Laparoscopic Surgery (FLS) scoring system. The secondary (visual detection) task was evaluated by calculating the rate of missed true signals or detection of false signals. RESULTS: Experts completed significantly more secure sutures (6 +/- 2) than novices (3 +/- 1; p = 0.001). The suture performance score was 50 +/- 20 for experts, significantly higher than for novices (29 +/- 10; p = 0.005). The rate for detecting visual signals was higher for experts (98%) compared with for novices (93%; p = 0.041). CONCLUSION: Practice develops automaticity, which reduces the mental workload and allows surgeons to have sufficient spare mental resources to attend to a secondary task. Visual detection provides a simple and reliable way to assess mental workload and situation awareness abilities of surgeons during skills training, and may be an indirect measure of expertise.

The importance of haptic feedback in laparoscopic suturing training and the additive value of virtual reality simulation.

INTRODUCTION: Previous studies on the difference between physical, augmented and virtual reality (VR) simulation state that haptic feedback is an important feature in laparoscopic suturing simulation. Objective assessment is important to improve skills during training. This study focuses on the additive value of VR simulation for laparoscopic suturing training. METHODS: All participants of several European Association for Endoscopic Surgery (EAES)-approved laparoscopic skills courses (N = 45) filled out a questionnaire on their opinion on laparoscopic suturing training. Additionally, participants with little or no laparoscopic suturing experience were allotted to two groups: group A (N = 10), who started training on the box trainer and subsequently the VR simulator (SimSurgery), and group B (N = 10), who began on the VR simulator followed by the box. Finally, suturing and knot-tying skills were assessed by an expert observer, using a standard evaluation form (eight items on five-point-Likert scale). The same was done after the initial training on the box in group A, as a control. Significant differences were calculated with the independent-sample t-test and the paired t-test. RESULTS: The total score of group A was higher than both group B and control (means of 30.80, 27.60, 28.20, respectively), but not significantly. The only tendency to a significant difference between group A and B was found in 'taking proper bites' (mean 4.10 versus 3.60, p = 0.054). All the participants scored the features of the box trainer significantly higher than those of the VR simulator (p < 0.001), 46.7% was of the opinion that the box alone would be sufficient for laparoscopic suturing training. CONCLUSION: From this study we can conclude that VR simulation does not have a significant additional value in laparoscopic suturing training, over traditional box trainers. One should consider that the future development in VR simulation should focus on basic skills and component tasks of procedural training in laparoscopic surgery, rather than laparoscopic suturing.

Medical staff attitudes toward family presence during pediatric procedures.

OBJECTIVE: Investigate health care providers' perceived advantages and disadvantages of family member presence (FMP) for a wide spectrum of procedures in the pediatric emergency department. SETTING: Urban tertiary care children's hospital. PARTICIPANTS: Pediatric emergency department faculty and nurses, pediatric residents. METHODS: In a written survey, participants rated approval of FMP for 9 procedures: intravenous (IV) placement, urinary catheterization, suturing, lumbar puncture, fracture reduction, chest tube placement, endotracheal intubation, medical resuscitation, and trauma resuscitation. Respondents listed advantages and disadvantages of FMP for patients, families, and staff. RESULTS: 71% (104/146) of the surveys were completed. Attending physicians and nurses provided similarly high approval rating for less invasive procedures, with a decrement in approval for more invasive or life-threatening situations. Attending physicians and nurses were more likely than residents to approve FMP for all procedures except IV placement, suturing, and urinary catheterization, which had similar approval rates for all respondents. Commonly expressed potential advantages were ability to calm the patient, decreased parental "helplessness," and increased parental knowledge that everything was done. Disadvantages included higher anxiety in room, disturbing parental memories, and detriment to success of the procedure. Medical-legal concerns, mistrust of providers, and more difficult teaching environment were uncommonly listed as disadvantages. CONCLUSIONS: Emergency department staff support FMP for minor procedures, yet express concern regarding the effects of this practice on the family and the success of the procedure. Most attending physicians and nurses support FMP during highly invasive procedures and resuscitations, whereas residents do not. This information provides insight into the educational and systematic requirements of implementation of FMP.

A review of 165 cases of transvaginal sacrospinous colpopexy performed by the Endo Stitch technique.

The Endo Stitch technique has been in use in Geelong since 1994 as the method of performing transvaginal sacrospinous colpopexy (TSC). This article looks at the outcome of 165 of these procedures as assessed by a questionnaire. As the operation is technically easy, has a low complication rate and a high level of patient satisfaction we suggest that the Endo Stitch technique may be the method of choice for TSC.