No abstract

Traditionally, surgical trainees have acquired their technical skills whilst working in the operating theatre alongside more senior surgeons in an apprenticeship model. Recently, changes in surgical practice have challenged this traditional approach, including reduced working hours, decreased availability of operating theatre time, increased cost of operating theatre time and increasing complexity of surgical procedures. Most importantly, public opinion is increasingly resistant to having patients used as teaching material. Moving forward in the 21st century, we need to develop a new model of technical skills acquisition. Surgical simulation offers a means of practicing surgical skills in a laboratory environment with no risk to patients. Simulators range from simple bench models, which are relatively inexpensive, to high tech virtual reality simulators. The Royal College of Surgeons in Ireland has developed a syllabus for operative surgery which is based on simulation and all trainees attend the National Surgical Training Centre on a regular recurrent basis, six times each year, for concentrated skills training. Simulation allows the standardisation of teaching technical skills and, most importantly, standardisation of assessment of technical skills. Furthermore, simulation offers trainees "permission to make mistakes" -a valuable learning exercise. Our trainees are assessed in the laboratory setting and must demonstrate proficiency before moving to the next stage of training (proficiency based progression). Simulation has played a key role in this process. PurposeAttaining procedural competence requires a combination of specific cognitive and psychomotor skills. The Multimedia Clinical Skills Trainer (MCST, GoVirtual Medical Ltd) is software program that integrates text, anatomy, video and simulation for teaching a range of procedures. The purpose of this study was to determine the face, content and construct validity of MCST for laparoscopic appendicectomy (LA). MethodologyThe study was supported by the RACS. Basic surgical trainees (BST) in NZ were recruited and randomized into a control group and an intervention group. The latter received MCST for ad libitum use on their personal computers. Participant received three questionnaires: at the start of the study to determine demographics, at 2 weeks to assess knowledge and problem solving ability, and at four months to assess operative confidence and usefulness of MCST. ResultsFifty-eight BST's were randomized. The first questionnaire was returned by 46% of participants, and third questionnaire by 44%. The intervention group scored more highly than the control group in the second questionnaire (14.69/20 vs 13.48/20). This difference was more apparent for first year BST's (14.93/20 vs 12.13/20, p = 0.04). Operative confidence was similar at four months for the two groups. First year BST's scored MCST more highly for its usefulness (5.2/7 vs 3.7/7, p = 0.04). ConclusionsMCST has face, content and construct validity for BST's learning LA, is a useful pre-learning t...

No abstract

No abstract

Introduction: Acutely decompensated heart failure (ADHF) usually results in hospitalisation for intravenous diuretics. The safety and efficacy of ambulatory or outpatient management of ADHF by heart failure specialist nurses has not been described before. Methods: This retrospective analysis compared 2 cohorts of consecutive ADHF patients - hospitalised in-patients (IP) versus outpatients (OP) who were treated with bolus intravenous diuretics in a specialist heart failure nurse delivered consultant led OP HF unit (Ambulatory HF Unit -AHFU) with input from various specialties (renal, diabetes, elderly care, chest, pharmacy, palliative, ascitic, pleural teams) from 2016 to 2020. Mean follow-up duration was similar for both groups (IP=46±8.1 months; OP=45.5± 7 months, p=0.1). We compared clinical risk scores using the Get With the Guidelines (GWTG) score, comorbidities using the Charlson Comorbidity Index (CCI) and frailty using the Rockwood Clinical Frailty Index (CFI). Results were expressed as mean±SD, analysed using the Student’s T test and Chi-squared test. Results: 1012 patients were treated in our specialist outpatient AHFU and 1889 patients were hospitalised. Mean number of visits per ambulatory spell was 5.1±-2.2 days and the median dose of furosemide was 220 mg (range 80-480). Average hospital stay for IP was 12.1±5 days. CCI (IP=6.5±2; OP=6.4±1.9; p=0.19) and mean GWTG scores were similar (IP=40.4±7.9; OP=39.9±7.1; p=0.09) between the 2 groups but mean Frailty Index was higher amongst the IP group (IP 5.1±1.2; OP 4.9±1; p=0<0.001). 30 day hospitalisation and mortality (30 day,1 year and overall mortality) were lower in the OP cohorts. Conclusions: Ambulatory management of ADHF using bolus IV diuretics in a heart failure specialist nurse delivered consultant led multidisciplinary unit offers an effective alternative to hospitalisation and also leads to improved outcomes. Frailty Index can help assess suitability for outpatient management of ADHF.