Reducing human error in urology: lessons from aviation

Application of Virtual Reality, Augmented Reality, and Mixed Reality in Endourology and Urolithiasis: An Update by YAU Endourology and Urolithiasis Working Group

The integration of virtual reality (VR), augmented reality (AR), and mixed reality (MR) in urological practices and medical education has led to modern training systems that are cost-effective and with an increased expectation toward surgical performance and outcomes. VR aids the user in interacting with the virtual environment realistically by providing a three-dimensional (3D) view of the structures inside the body with high-level precision. AR enhances the real environment around users by integrating experience with virtual information over physical models and objects, which in turn has improved understanding of physiological mechanisms and anatomical structures. MR is an immersive technology that provides virtual content to interact with real elements. The field of urolithiasis has adapted the technological advancements, newer instruments, and methods to perform endourologic treatment procedures. This mini-review discusses the applications of Virtual Reality, Augmented Reality, and Mixed Reality in endourology and urolithiasis.

[Pedagogical impact of a MOOC on surgical technique of kidney transplantation]

OBJECTIVE

To evaluate the educational impact of a pilot MOOC (Massive Open Online Course), validated by the French College of Urology Teachers (FCUT), on the surgical technique of kidney transplantation.

MATERIALS AND METHODS

We developed a MOOC on the surgical technique of kidney transplantation, based on a video of a surgical procedure, performed by an expert surgeon. The MOOC has been validated by the FCUT. We have created 2 student groups: 1) MOOC-pre-QCM group: visualization of the MOOC then answer to the MCQs and satisfaction questions; 2) MOOC-post-QCM group: answer to the MCQs then visualization of the MOOC then answers to the satisfaction questions. In total, 20 MCQs on the kidney transplantation technique were completed by the 2 groups. The answers were anonymous.

RESULTS

A total of 142 people answered the MCQs (MOOC-pre-QCM group (n=66) and MOOC-post-QCM group (n=76)). Twenty-nine percent (41/142) of the participants were fellows and 71 % (101/142) were residents. The proportion of fellows and residents was identical between the 2 groups. The rate of correct answers to the 20 MCQs was statistically higher in the MOOC-pre-QCM group, compared to the MOOC-post-QCM group (88.6 % versus 73.3 %, P<0.0001). Ninety-one percent of students found the MOOC "Very Useful" or "Useful". The median MOOC rating, given by students, was 8/10.

CONCLUSION

This study showed a positive impact of the MOOC on theoretical knowledge of kidney transplantation surgical technique. This MOOC could serve as a pilot project for the development of other MOOCs on urological surgery.

LEVEL

3.

Residents and patients benefit from surgical simulation on a live porcine model, could we consider it as ethical?

INTRODUCTION

The objective was to evaluate, by self-questionnaire, the feeling of participants in surgical training sessions on a live porcine model.

METHODS

A computerized questionnaire (GoogleForm ©) was sent to the members of the French Association of Urologists-in-Training (AFUF) (fellows and residents). Only questionnaires from Urologists-in-training who had participated in surgical training sessions were included. The sessions consisted of performing surgeries such as laparoscopic nephrectomies or laparoscopic cystectomies.

RESULTS

Overall, 198 met the inclusion criteria. A total of 36.4% (72/198) of the participants were fellows and 63.6% (126/198) were residents. According to the participants, the main interest of sessions was to be able to train for emergency situations. A total of 79.8% (158/198) of the participants wanted surgical simulation to become compulsory. To their opinion, the main advantage of surgical simulation on a live porcine model was: technical progress in 87.4% (173/198) of cases. A total of 13.1% (26/198) of the participants found it was unethical to perform the first technical procedures on live animal models. A total of 65.7% (130/198) of the participants considered that there is currently no system of substitution.

CONCLUSION

For the participants, surgical training on a live porcine model allows technical progress while training for serious emergency situations. Surgeons and patients could benefit from this risk-free mock surgical scenario.

LEVEL OF EVIDENCE

3.

A Visual Scale for Improving Communication When Describing Gross Hematuria

OBJECTIVE

To create and validate a grading scale that facilitates communication between providers managing gross hematuria (GH).

METHODS

A blood simulant was used to create a spectrum of GH in 5 foley catheter tubes which were shown to a group of experienced urologists. The urologists were asked how they would adjust the continuous bladder irrigation rate if the samples represented the urine of hypothetical patients, and a 5-point scale was created by group consensus with pictures of the representative tubes printed onto a visual aid. Another cohort were then shown the 5 tubes at random and asked to describe the GH. Raters were then shown the visual aid and asked to assign a grade to the same samples. Fleiss' kappa analysis was used to measure inter-rater agreement, and therefore fidelity of the scale.

RESULTS

Fourteen urologists were surveyed to determine the samples used to create the 5-point scale. After the scale was created, 43 raters (22 nurses, 16 urologists, and 5 advanced practice providers) attempted match the tubes to their corresponding images on the printout. When asked to describe the degree of GH for the samples as they would in clinical practice, 28 different descriptors were used (mean 8.6 per sample). When using the 5-point GH scale, however, raters exhibited near perfect agreement in matching each sample to its corresponding severity on the scale (κ = 0.93, P < .001).

CONCLUSION

We created a clinically useful GH scale that improves communication and reduces ambiguous language among providers of varying levels of experience.

Simulation in Urological Training and Education (SIMULATE): Protocol and curriculum development of the first multicentre international randomized controlled trial assessing the transferability of simulation-based surgical training

OBJECTIVES

To report the study protocol for the first international multicentre randomized controlled trial investigating the effectiveness of simulation-based surgical training and the development process for an evidence-based training curriculum, to be delivered as an educational intervention.

PARTICIPANTS AND METHODS

This prospective, international, multicentre randomized controlled clinical and educational trial will recruit urology surgical trainees who must not have performed ≥10 of the selected index procedure, ureterorenoscopy (URS). Participants will be randomized to simulation-based training (SBT) or non-simulation-based training (NSBT), the latter of which is the current sole standard of training globally. The primary outcome is the number of procedures required to achieve proficiency, where proficiency is defined as achieving a learning curve plateau of 28 or more on an Objective Structured Assessment of Technical Skills (OSATS) assessment scale, for three consecutive operations, without any complications. All participants will be followed up either until they complete 25 procedures or for 18 months. Development of the URS SBT curriculum took place through a two-round Delphi process.

RESULTS

A total of 47 respondents, consisting of trainees (n = 24) with URS experience and urolithiasis specialists (n = 23), participated in round 1 of the Delphi process. Specialists (n = 10) finalized the content of the curriculum in round 2. The developed interventional curriculum consists of initial theoretic knowledge through didactic lectures followed by select tasks and cases on the URO-Mentor (Simbionix, Lod, Israel) VR Simulator, Uro-Scopic Trainer (Limbs & Things, Bristol, UK) and Scope Trainer (Mediskills, Manchester, UK) models for both semi-rigid and flexible URS. Respondents also selected relevant non-technical skills scenarios and cadaveric simulation tasks as additional components, with delivery subject to local availability.

CONCLUSIONS

SIMULATE is the first multicentre trial investigating the effect and transferability of supplementary SBT on operating performance and patient outcomes. An evidence-based training curriculum is presented, developed with expert and trainee input. Participants will be followed and the primary outcome, number of procedures required to proficiency, will be reported alongside key clinical secondary outcomes, (ISCRTN 12260261).

Development of a program for teaching practical skills in visceral and digestive surgery by simulation

Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.

Current status of wet lab and cadaveric simulation in urological training: A systematic review

INTRODUCTION

We undertook a systematic review of the use of wet lab (animal and cadaveric) simulation models in urological training, with an aim to establishing a level of evidence (LoE) for studies and level of recommendation (LoR) for models, as well as evaluating types of validation.

METHODS

Medline, EMBASE, and Cochrane databases were searched for English-language studies using search terms including a combination of "surgery," "surgical training," and "medical education." These results were combined with "wet lab," "animal model," "cadaveric," and "in-vivo." Studies were then assigned a LoE and LoR if appropriate as per the education-modified Oxford Centre for Evidence-Based Medicine classification.

RESULTS

A total of 43 articles met the inclusion criteria. There was a mean of 23.1 (±19.2) participants per study with a median of 20. Overall, the studies were largely of low quality, with 90.7% of studies being lower than LoE 2a (n=26 for LoE 2b and n=13 for LoE 3). The majority (72.1%, n=31) of studies were in animal models and 27.9% (n=12) were in cadaveric models.

CONCLUSIONS

Simulation in urological education is becoming more prevalent in the literature, however, there is a focus on animal rather than cadaveric simulation, possibly due to cost and ethical considerations. Studies are also predominately of a low LoE; higher LoEs, especially randomized controlled studies, are needed.

Barriers to the Enhancement of Effective Communication in Neurosurgery

Communication issues play a major role within neurosurgery. There has been a growing awareness of the necessity of enhanced patient-centered communication between the physician and patient to improve patient satisfaction, compliance, and outcomes. In addition, the threat of malpractice litigation within neurosurgery is of particular concern, and improved communication may lead to some degree of risk mitigation. Within the neurosurgical and medical team, effective transmittal of vital clinical data is essential for patient safety. Despite the recent recognition of the critical role that communication plays in all aspects of medical care, multiple impediments hinder the improvement and use of effective techniques. We have identified 8 unique barriers to the advancement of communication practices: lack of recognition of the importance of communication skills; cognitive bias; sense that it "takes too much time"; cultural hierarchy within medicine; lack of formal communication skill training; fear that disclosure of medical errors will lead to malpractice litigation; the electronic medical record; and frequent shift changes and handoffs.

Examining patient safety attitudes among urology trainees

OBJECTIVES

To identify current attitudes to patient safety among urology trainees. To examine whether these have changed with the recent increase in emphasis on patient safety and the introduction of new working procedures in operating theatres.

SUBJECTS AND METHODS

Subjects included 28 urology trainees, based in the West of Scotland, UK. Trainee attitudes were examined using the Operating Room Management Attitudes Questionnaire, a validated tool for examining attitudes towards patient safety.

RESULTS

Attitudes to teamwork were highly positive, with 89-100% of trainees acknowledging the need to share information and conduct pre- and postoperative briefs, and 82-96% being accepting of multidisciplinary feedback on performance. Attitudes to preoperative briefing and multidisciplinary feedback were improved compared with a similar historical cohort. Trainees were reluctant to acknowledge the effect of stress and fatigue on personal performance; 50% felt they worked effectively in critical phases of operations even when tired, only 50% would tell team members their workload was becoming excessive and only 36% of trainees recognized that personal problems could affect their performance. There was no significant change in these attitudes from 2006 data. Regarding leadership and confidence assertion, 68% of trainees felt that leadership in the operating theatre should rest with the medical staff, 18% stated senior decisions or actions should not be questioned unless they threaten safety and 7% that they should not be questioned at all. This was similar to previous data.

CONCLUSIONS

Attitudes to briefing and multidisciplinary feedback appear to have improved since the introduction of the World Health Organization surgical checklist and wider use of feedback tools; other safety attitudes remain largely unchanged. Urology trainees may benefit from further training to better understand the mechanisms of error development, to raise awareness of human performance limitation, particularly the effects of stress and fatigue, and to develop techniques to challenge decisions/respond to challenges.

Interrupções e distrações na sala de cirurgia do trauma: entendendo a ameaça do erro humano

OBJETIVO: Compreender o fator humano como ameaça à segurança do paciente vítima de trauma no centro cirúrgico, traduzindo para a sala de operação algumas regras importantes já aplicadas no campo da aviação. MÉTODOS: A amostra incluiu 50 casos de cirurgia de trauma coletados prospectivamente por observadores em plantões de 12 horas, ,durante seis meses, em um centro de trauma nível I nos Estados Unidos da América. Informações quanto ao tipo de trauma, escore de gravidade e mortalidade foram coletadas, assim como, determinantes de distrações/interrupções e o volume de ruídos na sala de cirurgia durante o ato cirúrgico. RESULTADOS: Ocorreram, em média, 60 interrupções ou distrações durante o ato cirúrgico, na maioria das vezes desencadeado pelo movimento de pessoas na sala. Em pacientes mais graves (ISS > 45), submetidos ao controle de danos, a incidência de distrações foi ainda maior. A média de ruídos na sala de cirurgia do trauma foi muito elevada, com barulho próximo ao de um secador de cabelos. CONCLUSÃO: Interrupções e distrações são frequentes e devem ser estudadas pelo cirurgião do trauma a fim de desenvolver estratégias de prevenção e linhas de defesa para minimizá-las e reduzir seus efeitos.

Surgical Performance, Human Error and Patient Safety in Urological Surgery

Research has shown that about 10% of hospitalized patients suffer an adverse event as a result of the care that is delivered to them. In aiming to reduce the incidence of adverse events, a better understanding of the determinants of and contributors to surgical processes and outcomes is of paramount importance. On studying the literature some authors have focused on the degree of avoidable harm while others have focused on the development of measures that assess technical as well as non-technical skill in surgeons and surgical teams. This paper aims to review these developments and examine their existing applications and potential applicability to urological surgery. We then present a “systems approach” to surgical performance and apply it to urological surgery and conclude with immediate clinical applications of the systems approach and future directions for relevant surgical research.

Observational Teamwork Assessment for Surgery (OTAS): Refinement and Application in Urological Surgery

BACKGROUND

Teamwork in surgical teams is at the forefront of good practice guidelines and empirical research as an important aspect of safe surgery. We have developed a comprehensive assessment for teamwork in surgery-the Observational Teamwork Assessment for Surgery (OTAS)-and we have tested it for general surgical procedures. The aim of the research reported here was to extend the assessment to urology procedures.

METHODS

After refining the original assessment, we used it to observe 50 urology procedures. The OTAS comprises a procedural task checklist that assesses patient, equipment/provisions, and communication tasks as well as ratings on five team behavior constructs (communication, cooperation, coordination, leadership, and monitoring). Teamwork was assessed separately in the surgical, anesthesia, and nursing subteams in the operating theater. We also assessed the reliability of the behavioral scoring.

RESULTS

Regarding task completion, a number of communication and equipment/provisions tasks were not routinely performed during the operations we observed. Regarding teamwork-related behaviors, adequate reliability was obtained in the scoring of behaviors. Anesthetists and nurses obtained their lowest scores on communication. Surgeons' scores revealed a more complex pattern. In addition to low scores on communication, surgeons' teamwork behaviors appeared to deteriorate as the procedures were finishing.

CONCLUSIONS

Our findings suggest that OTAS is applicable to various branches of surgery. Separate assessment of the subteams in the operating theater provides useful information that can be used to build targeted teamwork training aiming to improve surgical patients' safety and outcomes.

Quantifying distraction and interruption in urological surgery

BACKGROUND

To enhance safety in surgery, it is necessary to develop a variety of tools for measuring and evaluating the system of work. One important consideration for safety in any high-risk work is the frequency and effect of distraction and interruption.

AIM

To quantify distraction and interruption to the sterile surgical team in urology.

METHODS

Observation of the behaviour of the surgical team and their task activity determined distraction and interruption recorded. Using an ordinal scale, an observer rated each salient distraction or interruption observed in relation to the team's involvement.

RESULTS

The frequency of events and their attached ratings were high, deriving from varying degrees of equipment, procedure and environment problems, telephones, bleepers and conversations.

DISCUSSION

With further refinement and testing, this method may be useful for distinguishing ordinal levels of work interference in surgery and helpful in raising awareness of its origin for postoperative surgical team debriefing.