Assessment Of Learning Curve Research Articles

Learning curve assessment in 102 laparoscopic distal pancreatectomies: single surgeon series

Introduction: Laparoscopic distal pancreatectomy (LDP) has become standard treatment for left-sided pancreatic disease in expert centers. However, large (>30 cases) single surgeon series assessing the surgical learning curve are lacking. Methods: Data of patients undergoing LDP between June 2007 and April 2015 were prospectively collected. LDPs were performed by a single surgeon (MAH). Patients were divided into three equal groups of consecutive LDPs. Results: In total, 102 LDPs were performed (age 61 years (IQR = 44.5–70.0), 63% (n = 64) female). Two LDPs (2%) were converted. Operative time was 205 min. (SD = 75), blood loss 200 mL (IQR = 50–300). Groups were comparable for baseline, operative time and blood loss. The use of LDPs including the pancreatic body (group 1 = 29%, 2 = 47%, 3 = 47%; p = 0.04) and multivisceral resections (group 1=6%, 2 = 15%, 3 = 21%; p = 0.21) increased with time. The Clavien–Dindo ≥3 complication rate decreased (24%, 6% and 3% for group 1, 2 and 3; p = 0.02), whereas the ISGPF grade B/C fistula rate showed a non-significant increase (35%, 59% and 53%; p = 0.13), because more patients were discharged with a drain in situ in groups 2 and 3. Due to this change in drain management, a reduction in percutaneous drainage was achieved (21%, 6% and 1%; p = 0.03). Hospital stay decreased (9, 6 and 4 days for group 1, 2 and 3; p < 0.001). Conclusion: No learning curve for operative time was found, possibly due to more difficult procedures performed with growing experience. Nevertheless, a steady improve in postoperative outcomes was observed throughout the whole series.

Does Increased Experience with Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Lead to Decreased Flap Loss? The Learning Effect

Early studies have shown that near-infrared monitoring with tissue oximetry shows promise in providing earlier detection of free flap vascular compromise. However, large-scale clinical evaluation of this technology on flap outcome has not previously been established. This study examines the effect of tissue oximetry on flap reexploration rates and salvage over a 10-year period. The learning curve for this new technology is also assessed. A retrospective review was performed of prospectively maintained data on all microsurgical breast reconstructions performed at an academic institution from 2004 to 2014. Patients were divided into two separate cohorts--standard clinical monitoring and standard clinical monitoring plus tissue oximetry--and rates of reexploration and flap salvage were compared. Subgroup analysis (tertiles) was performed to assess outcomes with increasing experience. A total of 380 flaps (36.2 percent) received standard clinical monitoring, and 670 flaps (63.8 percent) received additional tissue oximetry monitoring. The rate of flap salvage before implementation of tissue oximetry monitoring was 57.7 percent and increased to 96.6 percent (p < 0.001). The number of complete flap losses decreased from 11 (2.9 percent) to one (0.1 percent) with the use of tissue oximetry (p < 0.001). Subgroup analysis demonstrated significantly fewer reexplorations in the third tertile. Inclusion of continuous tissue oximetry in the postoperative monitoring protocol of microsurgical breast reconstruction is associated with significantly improved salvage rates and fewer flap losses. Furthermore, learning curve assessment demonstrates that use of tissue oximetry can decrease the rate of reexploration over time.

A CT-Based Analysis of Implant Position of Sacroiliac Joint Fusion: Is There a Learning Curve for Safe Placement?

Introduction Diagnosis of degenerative sacroiliitis and surgical interventions are increasing. Open and minimally invasive sacroiliac joint (MIS SIJ) techniques exist. Optimal rod placement requires adequate training to minimize risk of breaching vital structures such as sacral anterior cortex (AC) and neural foramina (NF). CTbased image guidance navigation increases accuracy of rod placement. This study describes a retrospective singlesurgeon postoperative assessment of implant position in navigated MIS SIJ fusion procedures over a 5-year period. Materials and Methods Early (1st 3 years) versus late (past 2 years) cases were evaluated to assess learning curve of implant placement accuracy. Grading scheme was created to assess SIJ fusion rod placement and potential risk of guide pin breaching either AC and/or NF. Grade 1 denotes least risk of breach; Grade 2 denotes partial risk of breech by the implant but not the guide pin; Grade 3 denotes risk of breach of both pin and implant; Grade 4 denotes actual breach. Rod fixation grading was based on bony purchase ratio between iliac and sacral side of the joint where: Grade 1: &gt; 50% of rod occupies sacral side; Grade 2: 50% of rod is fixed on sacral side; Grade 3: &lt; 50% of rod is fixed on sacral side and Grade 4: rod does not cross SIJ. Results From 2010 to 2014, 110 implants in 39 SI joint fusions in 33 patients were assessed. Of these 55% were placed atS1 level, 40% were S2 and 5% were in S3. Majority of rods were placed in optimal position (Grade 1 40%68%). The position of 48 rods in 1st 3 years were compared 62 rods in past 2 years. Greater percentage of rods were classified as Grade 1 in the last two years (68%, 65%) compared with the first 3 years (56%, 33%, 25%) indicating a learning curve and improved safety profile of rod placement over time. Conclusions This study demonstrates that a learning curve exists with the use of 3D CT guidance for SI joint implant placements. This proposed grading system can be used to aid in optimal placement of SI joint implants.

Assessment of the Male Urethral Reconstruction Learning Curve

To evaluate the urethroplasty learning curve. Published success rates of urethral reconstruction for urethral stricture disease are high even though these procedures can be technically demanding. It is likely that success rates improve with time although a learning curve for urethral reconstruction has never been established. We retrospectively reviewed anterior urethroplasties from a prospectively maintained multi-institutional database. Success was analyzed at the 18-month mark in all patients and defined as freedom from secondary operation for stricture recurrence. A multivariate logistic regression was performed for outcomes vs time from fellowship and case number. A total of 613 consecutive cases from 6 surgeons were analyzed, with a functional success rate of 87.3%. The success rate for bulbar urethroplasties was higher than that for penile urethroplasties (88.2% vs 78.3%, P = .0116). The success rate of anastomotic repairs was higher than that for substitution repairs (95.0% vs 82.4%, P = .0001). There was a statistically significant trend toward improved outcomes with increasing number of cases (P = .0422), which was most pronounced with bulbar repairs. There was no statistical improvement in penile repairs over time. The case number to reach proficiency (>90% success) was approximately 100 cases for all types of reconstruction and 70 cases for bulbar urethroplasty. There were statistical differences in success rates among the participating surgeons (P = .0014). Complications decreased with time (P = .0053). This study shows that success rates of anterior urethral reconstruction improve significantly with surgeon experience. Proficiency occurs after approximately 100 cases.

Variation of safety indices during in the learning curve for color Doppler assessment of the fetal heart at 11+0 to 13+6 weeks' gestation.

The aim of our study was to analyze the variation of acoustic output, as expressed by the thermal (TI) and mechanical index (MI), during the learning curve for a fetal heart scan at 11-13 gestational weeks, with the introduction of a new ultrasound system. This was a prospective, observational study on 303 normal fetuses. The fetal heart was examined transabdominally using B-Mode and high definition (HD) color Doppler to obtain standard parameters: four-chamber, outflow tracts and three-vessel-trachea views. Data were analyzed in groups of 20 consecutive examinations and the percentage of successful examinations was calculated. TI and MI were retrieved from HD color Doppler examinations of the fetal heart and from pulsed-wave Doppler assessment of the tricuspid flow and ductus venosus. MI values from the color Doppler examination of the fetal heart showed a continuous decrease (0.81 to 0.75, p<0.001), along the learning phase. TI and MI indices from pulsed-wave Doppler evaluation of the tricuspid flow increased at the beginning of the learning phase and stabilized afterwards (0.34 to 0.36, p<0.05 and 0.37 to 0.4, p<0.001, respectively). TI from color Doppler exam of the heart and indices from ductus venosus assessment were very constant and did not change along the studied periods. The length of Doppler examination of the heart increased after about 80 cases by 25%, to a mean of 4 minutes (p<0.05). Safety indices from Doppler evaluation of the fetal heart and tricuspid flow vary during the learning curve for fetal heart assessment. Also, the occurrence of constant values suggests the potential for their supplementary active reduction. For a better adaptation to a new ultrasound technology, the sonographer should scan the fetal heart longer in the first trimester and follow displayed safety indices along the first 80 cases.

Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment

BackgroundUse of robot-assisted radical prostatectomy (RARP) for prostate cancer is increasing. Structured surgical training and objective assessment are critical for outcomes. ObjectiveTo develop and validate a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves (LCs) for procedural steps. Design, setting, and participantsThis multi-institutional (Europe, Australia, and United States) observational prospective study used HFMEA to identify the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. Results produced LCs for each step. A plateau above score 4 indicated competence. Outcome measurements and statistical analysisWe used a modular training and assessment tool (RARP Assessment Score) to evaluate technical skills. LCs were constructed. Multivariable Kruskal-Wallis, Mann-Whitney U, and κ coefficient analyses were used. Results and limitationsFive surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with a hazard score ≥8. Content validation created the RARP Assessment Score: 17 stages and 41 steps. The RARP Assessment Score was acceptable (56.67%), feasible (96.67%), and had educational impact (100%). Fifteen robotic surgery trainees were assessed for 8 mo. In 426 RARP cases (range: 4–79), all procedural steps were attempted by trainees. Trainees were assessed with the RARP Assessment Score by their expert mentors, and LCs for individual steps were plotted. LCs demonstrated plateaus for anterior bladder neck transection (16 cases), posterior bladder neck transection (18 cases), posterior dissection (9 cases), dissection of prostatic pedicle and seminal vesicles (15 cases), and anastomosis (17 cases). Other steps did not plateau during data collection. ConclusionsThe RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. LCs demonstrate the experience necessary to reach a level of competence in technical skills to protect patients. Patient summaryWe developed a safety and assessment tool to gauge the technical skills of surgeons performing robot-assisted radical prostatectomy. Improvement was monitored, and measures of progress can be used in future to guide mentors when training surgeons to operate safely.

Su1558 Preclinical Endoscopic Training Using a Part-Task Simulator: Learning Curve Assessment and Determination of Threshold Score for Advancement to Clinical Endoscopy

Background Preclinical simulator training has the potential to decrease endoscopic procedure time and patient discomfort. This study aims to characterize the learning curve of endoscopic novices in a part-task simulator and propose a threshold score for advancement to initial clinical cases.

Formation of the Scandinavian Obesity Surgery Registry, SOReg.

Obesity surgery is expanding, the quality of care is ever more important, and learning curve assessment should be established. A large registry cohort can show long-term effects on obesity and its comorbidities, complications, and long-term side effects of surgery, as well as changes in health-related quality of life (QoL). Sweden is ideally suited to the task of data collection and audit, with universal use of personal identification numbers, nation-wide registries permitting cross-matching to analyze causes of death, in-hospital care, and health-related absenteeism. In 2004, the Scandinavian Obesity Surgery Registry (SOReg) was initiated and government financing secured. A project group created a national database covering all public as well as private hospitals. Data entry was to be made online, operative definitions of comorbidity were formed, and complication severity scored. Several forms of audit were devised. After pilot studies, the system has been running in its present form since 2007. Since 15 January 2013, SOReg covers all bariatric surgery centers in Sweden. The number of operations in the database exceeded 40,000 (March 2014), with a median follow-up of 2.94 years. Audit shows that >98% of data are correct. All results are publicized annually on the Internet. Using this systematic approach, it has been possible to cover >99% of all bariatric surgery, cross-matching our data with nation-wide registries for in-hospital care, cause of death, and permitting regular nation-wide audit. Several scientific studies have used, or are using, what seems to be the most comprehensive database in obesity surgery.

Radio-frequency ablation vs. open surgery in the treatment of varicose veins - a comparative study

Methods This was a single centre retrospective cohort study. All patients with confirmed sapheno-femoral junctional incompetence who underwent surgical management treatment between January 2011 and December 2012 were included. Medical charts and computer records were reviewed. Radiological success, choice of anaesthesia and hospital length of stay was documented. Procedural cost was also calculated. A focused cohort analysis was undertaken to compare the initial 50 RFA procedures performed with the last 50. This allowed for departmental learning curve assessment over a 13-month period.

P23.05: Variation of safety indices during learning curve for assessment of fetal heart at 11 + 0 to 13 + 6 weeks' gestation

<scp>P</scp>23.05: Variation of safety indices during learning curve for assessment of fetal heart at 11 + 0 to 13 + 6 weeks' gestation

An object location memory paradigm for older adults with and without mild cognitive impairment.

Object-location memory is critical in every-day life and known to deteriorate early in the course of neurodegenerative disease. We adapted the previously established learning paradigm "LOCATO" for use in healthy older adults and patients with mild cognitive impairment (MCI). Pictures of real-life buildings were associated with positions on a two-dimensional street map by repetitions of "correct" object-location pairings over the course of five training blocks, followed by a recall task. Correct/incorrect associations were indicated by button presses. The original two 45-item sets were reduced to 15 item-sets, and tested in healthy older adults and MCI for learning curve, recall, and re-test effects. The two 15-item versions showed comparable learning curves and recall scores within each group. While learning curves increased linearly in both groups, MCI patients performed significantly worse on learning and recall compared to healthy controls. Re-testing after 6 month showed small practice effects only. LOCATO is a simple standardized task that overcomes several limitation of previously employed visuospatial task by using real-life stimuli, minimizing verbal encoding, avoiding fine motor responses, combining explicit and implicit statistical learning, and allowing to assess learning curve in addition to recall. Results show that the shortened version of LOCATO meets the requirements for a robust and ecologically meaningful assessment of object-location memory in older adults with and without MCI. It can now be used to systematically assess acquisition of object-location memory and its modulation through adjuvant therapies like pharmacological or non-invasive brain stimulation.

Systematic Review of Learning Curves for Minimally Invasive Abdominal Surgery

To determine how minimally invasive surgical learning curves are assessed and define an ideal framework for this assessment. Learning curves have implications for training and adoption of new procedures and devices. In 2000, a review of the learning curve literature was done by Ramsay et al and it called for improved reporting and statistical evaluation of learning curves. Since then, a body of literature is emerging on learning curves but the presentation and analysis vary. A systematic search was performed of MEDLINE, EMBASE, ISI Web of Science, ERIC, and the Cochrane Library from 1985 to August 2012. The inclusion criteria are minimally invasive abdominal surgery formally analyzing the learning curve and English language. 592 (11.1%) of the identified studies met the selection criteria. Time is the most commonly used proxy for the learning curve (508, 86%). Intraoperative outcomes were used in 316 (53%) of the articles, postoperative outcomes in 306 (52%), technical skills in 102 (17%), and patient-oriented outcomes in 38 (6%) articles. Over time, there was evidence of an increase in the relative amount of laparoscopic and robotic studies (P < 0.001) without statistical evidence of a change in the complexity of analysis (P = 0.121). Assessment of learning curves is needed to inform surgical training and evaluate new clinical procedures. An ideal analysis would account for the degree of complexity of individual cases and the inherent differences between surgeons. There is no single proxy that best represents the success of surgery, and hence multiple outcomes should be collected.

Learning curve for fetoscopic laser surgery using cumulative sum analysis.

To identify a learning curve and monitor operator performance for fetoscopic laser surgery for twin-to-twin transfusion syndrome using cumulative sum analysis. Retrospective cohort study. National tertiary referral center for invasive fetal therapy. A total of 340 consecutive monochorionic pregnancies with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation between August 2000 and December 2010. A learning curve was generated using learning curve cumulative sum analysis and cumulative sum methodology to assess changes in double survival across the case sequence. Laser surgery was initially performed by two operators, joined by a third and fourth operator after 1 and 2years, respectively. Individual operator performance, double perinatal survival at 4weeks. Overall survival of both twins occurred in 59% (201/340), median gestational age at birth was 32.0weeks. Cumulative sum graphs showed that level of competence for double survival for the operators was reached after 26, 25, 26, and 35 procedures, respectively. Two operators kept their competence level and continued to improve after completing the initial learning process; two others went out of control at one point in time, according to the cumulative sum boundaries. A difference in learning effect was associated with number of procedures performed annually and previous experience with other ultrasound-guided invasive procedures. This study shows that all operators reached a level of competence after at least 25 fetoscopic laser procedures and confirms the value of using the cumulative sum method both for learning curve assessment and for ongoing quality control.

Su1643 Assessment of Balloon-Assisted Cholangioscopy Learning Curve With Respect To Parameters of Procedural Competence and Safety

Su1643 Assessment of Balloon-Assisted Cholangioscopy Learning Curve With Respect To Parameters of Procedural Competence and Safety

Learning Curves in 3‐Dimensional Sonographic Follicle Monitoring During Controlled Ovarian Stimulation

Three-dimensional (3D) sonographically based automated volume calculation (SonoAVC; GE Healthcare, Zipf, Austria) is being introduced in folliculometry during ovarian stimulation; however, clear training assessments in this technique are lacking. The learning curve-cumulative summation (LC-CUSUM) test provides a quantitative tool to determine when a trainee has learned a procedure. The aim of this prospective study was to assess 3D SonoAVC LC-CUSUM curves in folliculometry. Analyses were performed on 98 oocyte donors by capturing the ovarian image in 3D and applying the 3D SonoAVC software during ovarian stimulation cycles. Each patient was scanned by an expert operator and by a trainee. Independent LC-CUSUM tests for 4 follicular diameters tracked the competency of 3 trainees in 3D SonoAVC. We found that the numbers of sonographic examinations required by the 3 trainees to identify the correct number of follicles of 10 mm or larger were 38, 32, and 28, respectively; for follicles of 14 mm or larger, they were 29, 28, and 28; for follicles of 18 mm or larger, they were 24, 19, and 27; and for follicles of 21 mm or larger, they were 29, 19, and 24. A variable number of procedures are needed to reach proficiency in 3D SonoAVC, even for trained 2-dimensional sonographers. Assessment of learning curves should be implemented when incorporating 3D SonoAVC in reproduction units.

MP5-10 ROBOTIC INTRA-CORPOREAL ORTHOTOPIC NEOBLADDER DURING RADICAL CYSTECTOMY: 132 PATIENTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion1 Apr 2014MP5-10 ROBOTIC INTRA-CORPOREAL ORTHOTOPIC NEOBLADDER DURING RADICAL CYSTECTOMY: 132 PATIENTS Mihir M. Desai, Inderbir Gill, Abolfazl Hosseini, Tommy Nyberg, Christofer Adding, Oscar Laurin, Justin Collins, Andre Luis Abreu, Alvin Goh, Monish Aron, and Peter Wiklund Mihir M. DesaiMihir M. Desai More articles by this author , Inderbir GillInderbir Gill More articles by this author , Abolfazl HosseiniAbolfazl Hosseini More articles by this author , Tommy NybergTommy Nyberg More articles by this author , Christofer AddingChristofer Adding More articles by this author , Oscar LaurinOscar Laurin More articles by this author , Justin CollinsJustin Collins More articles by this author , Andre Luis AbreuAndre Luis Abreu More articles by this author , Alvin GohAlvin Goh More articles by this author , Monish AronMonish Aron More articles by this author , and Peter WiklundPeter Wiklund More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.393AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To present a 2-institutional experience with completely intra-corporeal robotic orthotopic neobladder and robotic radical cystectomy in 132 patients. METHODS Of 246 robotic intra-corporeal diversions, 132 were neobladders. All neobladders were constructed intra-corporeally in a globular configuration, completely duplicating established open surgical techniques. Demographics: mean age 60 years, BMI 27, female patients n=18 (14%), status-post neo-adjuvant chemotherapy n=30 (23%). Technical details: nerve-sparing in 56% of male patients, female organ-preserving in 32% of female patients; Lymphadenectomy: Extended (upto aortic bifurcation): n=51 (39%), Super-extended (upto IMA): n=20 (15%); Uretero-ileal anastomoses: Wallace-type (n=86; 65%), Bricker-type (n=46; 35%). Data were prospectively collected. Patients were retrospectively divided into chronologic groups to assess learning curve trends. RESULTS Mean data: OR time 7.6 hrs (4.4-13), blood loss 430 cc (50-2200), hospital stay 11 days (3-78). Complications: Clavien grade I, II, IIIa, IIIb, IV and V: Within 30 days: 7%, 25%, 9%, 4%, 2% and 0%; Between 30-90 days: 5%, 9%, 2%, 8%, 1% and 1.5%. Bowel complications: n=2 (1.5%) (ileo-neobladder fistula, bowel leak). Benign uretero-enteric strictures: n=5 (3.8 %). On comparing the initial 25 with the latest 32 patients, outcomes improved significantly: mean OR time (8.2 vs 7.3 hrs), blood loss (694 vs 319 cc) and hospital stay (12.6 vs 7.7 d). Positive surgical margin: n=1 (0.8%). Mean nodal yield: 29 (7-164), node-positivity rate was 17%. Over a mean follow-up of 2.1 years (0.1-9.8), cancer recurred in 20 patients (15%), 5-year overall, cancer-specific and recurrence-free survival was 72%, 72% and 71%, respectively. CONCLUSIONS Robotic intra-corporeal orthotopic neobladder diversion is now a developed and refined technique, diligently duplicating open principles. Operative efficiency and peri-operative outcomes have improved significantly with experience. Nodal yield, pathologic data and 5-year oncologic outcomes are equivalent to open surgery. As the next step, we propose a randomized controlled trial with open radical cystectomy/neobladder surgery, including objective assessment of functional outcomes. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e85-e86 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Mihir M. Desai More articles by this author Inderbir Gill More articles by this author Abolfazl Hosseini More articles by this author Tommy Nyberg More articles by this author Christofer Adding More articles by this author Oscar Laurin More articles by this author Justin Collins More articles by this author Andre Luis Abreu More articles by this author Alvin Goh More articles by this author Monish Aron More articles by this author Peter Wiklund More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Operator learning curve for transradial percutaneous coronary interventions: implications for the initiation of a transradial access program in contemporary US practice

Our study aimed to assess the characteristics and outcomes of transfemoral approach (TFA) versus the initial steps of a transradial approach (TRA) program and to assess the learning curve of TRA in contemporary, US practice. When compared to TFA, TRA has been shown to lower bleeding and vascular complications during percutaneous coronary intervention (PCI). However, use of TRA is still low. There are limited data regarding the characteristics of TRA learning curve, especially in an era with designated TRA equipment. Consecutive patients undergoing PCI in a single US center were divided into two cohorts according to vascular access approach: the last 250 TFA patients prior to the establishment of a TRA program and the initial 239 TRA patients following the establishment of a TRA program. Subgroup analysis of the TRA group, which was divided into five sequential case groups of 50 cases per group, was performed in order to assess TRA learning curve. Overall, the baseline characteristics of TFA vs. TRA groups were comparable. Fluoroscopy time was significantly longer during TRA procedures (18±11 vs. 15±8min, respectively, p=0.002); however, contrast use was lower during TRA procedures (161±72 vs. 180±63ml, respectively, p=0.002). In-hospital outcomes were similar between the two groups, with low frequencies of mortality, myocardial infarction, and stent thrombosis. Subanalysis of TRA group for learning curve assessment showed no major differences in patient demographics among the five subgroups. In the initial cases, more PCI was performed among non-acute cases (62% in patients 1-50 vs. 8-27% in patients 51-239, p<0.001). Despite these differences, characteristics of the treated vessels were similar between groups. There was no significant change in fluoroscopy time or in the amount of iodinated contrast volume delivered. Similarly, no differences in procedural, in-hospital, and long-term outcomes were documented. Adopting TRA as a default is feasible for high-volume operators without significant learning curve effects.

Student Attainment of Proficiency in a Clinical Skill: The Assessment of Individual Learning Curves

The aims of this study were to determine if the learning curve cumulative summation test (LC-CUSUM) can differentiate proficiency in placing intravenous catheters by novice learners, and identify the cause of failure when it occurred. In a prospective, observational study design 6 undergraduate students with no previous experience of placing intravenous catheters received standardized training by a board certified veterinary anesthesiologist in intravenous catheter placement technique. Immediately following training, each student attempted 60 intravenous catheterizations in a dog mannequin thoracic limb model. Results were scored as a success or failure based upon completion of four specific criteria, and where catheter placement failure occurred, the cause was recorded according to pre-defined criteria. Initial acceptable and unacceptable failure rates were set by the study team and the LC-CUSUM was used to generate a learning curve for each student. Using 10% and 25% acceptable and unacceptable failure rates, 3 out of 6 students attained proficiency, requiring between 26 to 48 attempts. Applying 25% and 50% acceptable and unacceptable failure rates, 5 of 6 students obtained proficiency, requiring between 18 and 55 attempts. Wide inter-individual variability was observed and the majority of failed catheterisation attempts were limited to two of the four pre-defined criteria. These data indicate that the LC-CUSUM can be used to generate individual learning curves, inter-individual variability in catheter placement ability is wide, and that specific steps in catheter placement are responsible for the majority of failures. These findings may have profound implications for how we teach and assess technical skills.

Learning Curve Assessment of Robot-Assisted Radical Prostatectomy Compared with Open-Surgery Controls from the Premier Perspective Database

The primary aims of this study were to assess the learning curve effect of robot-assisted radical prostatectomy (RARP) in a large administrative database consisting of multiple U.S. hospitals and surgeons, and to compare the results of RARP with open radical prostatectomy (ORP) from the same settings. The patient population of study was from the Premier Perspective Database (Premier, Inc., Charlotte, NC) and consisted of 71,312 radical prostatectomies performed at more than 300 U.S. hospitals by up to 3739 surgeons by open or robotic techniques from 2004 to 2010. The key endpoints were surgery time, inpatient length of stay, and overall complications. We compared open versus robotic, results by year of procedures, results by case volume of specific surgeons, and results of open surgery in hospitals with and without a robotic system. The mean surgery time was longer for RARP (4.4 hours, standard deviation [SD] 1.7) compared with ORP (3.4 hours, SD 1.5) in the same hospitals (p<0.0001). Inpatient stay was shorter for RARP (2.2 days, SD 1.9) compared with ORP (3.2 days, SD 2.7) in the same hospitals (p<0.0001). The overall complications were less for RARP (10.6%) compared with ORP (15.8%) in the same hospitals, as were transfusion rates. ORP results in hospitals without a robot were not better than ORP with a robot, and pretreatment co-morbidity profiles were similar in all cohorts. Trending of results by year of procedure showed no differences in the three cohorts, but trending of RARP results by surgeon experience showed improvements in surgery time, hospital stay, conversion rates, and complication rates. During the initial 7 years of RARP development, outcomes showed decreased hospital stay, complications, and transfusion rates. Learning curve trends for RARP were evident for these endpoints when grouped by surgeon experience, but not by year of surgery.

22 A prospective randomized study of a new articulating laparoscopy device (Kymerax-Terumo) in the dry lab – part 1: Learning curve and objective skills assessment

22 A prospective randomized study of a new articulating laparoscopy device (Kymerax-Terumo) in the dry lab – part 1: Learning curve and objective skills assessment