- Email: [email protected]
Mobile application to analyse surgical experience
ARTICLE IN PRESS n e u r o c i r u g i a . 2 0 1 9;x x x(x x):xxx–xxx
NEUROCIRUGÍA www.elsevier.es/neurocirugia
Special article
Mobile application to analyse surgical experience夽 Everardo Garcia-Estrada, Jesús A. Morales-Gómez ∗ , Miriam Delgado-Brito, Ari A. Martínez-López, Luis E. Flores-Huerta, Ángel R. Martínez-Ponce de León Servicio de Neurocirugía y Terapia Endovascular Neurológica, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To quantify the surgical experience acquired by residents in the neurosurgery
Received 25 September 2018
specialisation programme over a 6-month period.
Accepted 9 September 2019
Materials and methods: A total of 13 residents enrolled in the neurosurgery specialisation
Available online xxx
programme from February 2018 to July 2018. Over this period, the procedures residents
Keywords:
Register. Residents who withdrew from the specialisation programme were excluded.
Surgical register
Results: A total of 530 procedures were performed during the study period. Observational
were involved in and the role they played were documented in the Electronic Neurosurgical
Neurosurgery
learning and supervised practice are conducted primarily in the first and fifth years of res-
Supervision
idence, during which residents begin their training in emergency and elective surgeries,
Surgical teaching
respectively. Residents are then able to independently perform emergency surgeries during
Resident
the second and third years, and elective surgeries in the sixth year. Residents are able to
Electronic register
instruct less experienced surgeons in the fourth year. Conclusions: The Electronic Neurosurgical Register is an innovative technological tool that supports the fields of care, teaching and research. It records the exact number of patients who have undergone surgery at a particular time, providing valuable information for the proper management of resources. The data obtained can be used to identify areas of opportunity in the training of residents, facilitating the development of continuous improvement strategies in the training of competent neurosurgeons. ˜ ˜ S.L.U. All rights © 2019 Sociedad Espanola de Neurocirug´ıa. Published by Elsevier Espana, reserved.
DOI of original article: https://doi.org/10.1016/j.neucir.2019.09.001. Please cite this article as: Garcia-Estrada E, Morales-Gómez JA, Delgado-Brito M, Martínez-López AA, Flores-Huerta LE, Martínez-Ponce de León ÁR. Aplicación móvil para el análisis de la experiencia quirúrgica. Neurocirugia. 2019. https://doi.org/10.1016/j.neucir.2019.09.001 ∗ Corresponding author. E-mail address: [email protected] (J.A. Morales-Gómez). ˜ ˜ S.L.U. All rights reserved. 2529-8496/© 2019 Sociedad Espanola de Neurocirug´ıa. Published by Elsevier Espana, 夽
NEUCIE-399; No. of Pages 6
ARTICLE IN PRESS 2
n e u r o c i r u g i a . 2 0 1 9;x x x(x x):xxx–xxx
Aplicación móvil para el análisis de la experiencia quirúrgica r e s u m e n Palabras clave:
Objetivo: Cuantificar la experiencia quirúrgica obtenida por los residentes del programa de
Registro quirúrgico
especialización en neurocirugía durante un periodo de 6 meses.
Neurocirugía
Material y método: Un total de 13 residentes se registraron en el programa de especialización
Supervisión
en neurocirugía en el periodo de febrero a julio de 2018. Durante este periodo se docu-
˜ quirúrgica Ensenanza
mentaron en el Registro Neuroquirúrgico Electrónico los procedimientos en los que cada
Residente
˜ Los residentes que se retiraron del programa residente participó y el rol que desempenó.
Registro electrónico
fueron excluidos. Resultados: Se realizaron 530 procedimientos en el periodo de estudio. El aprendizaje por ˜ de observación y la práctica tutelada se realizan principalmente en el primer y quinto ano residencia, periodos durante los cuales el residente comienza su aprendizaje en el área cirugías de urgencias y electivas, respectivamente. Posteriormente es capaz de realizar ˜ y cirugías de manera autónoma, en el bloque de urgencias, durante el segundo y tercer ano; ˜ El residente es capaz de instruir a cirujanos en el bloque de cirugías electivas, en el sexto ano. ˜ menos experimentados en el cuarto ano. Conclusiones: El Registro Neuroquirúrgico Electrónico es una herramienta tecnológica innovadora que apoya en los campos de asistencia, docencia e investigación. Permite conocer con exactitud la cantidad de pacientes que han sido intervenidos quirúrgicamente en un determinado momento, lo cual brinda información valiosa para el manejo adecuado de recursos. Los datos obtenidos permiten identificar áreas de oportunidad en el entrenamiento de los residentes, lo que permite el desarrollo de estrategias para la mejora continua en la formación de neurocirujanos competentes. ˜ ˜ S.L.U. Todos © 2019 Sociedad Espanola de Neurocirug´ıa. Publicado por Elsevier Espana, los derechos reservados.
Introduction The neurosurgery training programme aims to produce surgeons capable of independent practice. The methodology in the training to train competent surgeons is similar among institutions; however, even in the same institution there are differences in the degree of surgical experience acquired by each resident.1 To become competent in neurosurgery, postgraduate students must learn to manage nerve tissue in an appropriate, gentle and precise manner. Historically, skills have been acquired with the premise of “See one, do one, teach one”.2 Novice residents face surgical procedures for the first time and rely heavily on close supervision by a mentor.2 Gradually, the resident will acquire skills necessary for independent practice2 and thus will have the ability to perform certain procedures on his or her own. Analysing the number of procedures that each resident has performed in the different roles will identify those who learn slower and, therefore, require additional support in their training.3 An easy-to-use portable database4 that automatically generates reports covering the educational and quality aspects of the resident’s experience5 is useful for this analysis. With this objective, the Neurosurgery and Endovascular Neurological Therapy Department of the Hospital Universitario “Dr. José Eleuterio González” UANL [UANL University Hospital “Dr. José Eleuterio González”] developed a mobile application: “Electronic Neurosurgical Registry” that can be used with a
computer or with a mobile device compatible with the programme and an Internet connection. The objective of this study was to quantify the surgical experience obtained by residents of the neurosurgery specialisation programme over a period of six months. This information can help us identify deficiencies; not only of individual training, but also within the institutions and the neurosurgery specialisation programme in order to maintain the quality of surgical training.
Material and methods The “Electronic Neurosurgical Registry” is a technological solution generated to share information that guarantees patients’ confidentiality as well as the integrity and reliability of clinical information; in addition, it establishes pertinent and adequate security measures, in order to avoid the illegal or illegitimate use of the information.6 For the development of this tool, recommendations made after the analysis of other electronic registries were taken into account. Fields that allow free text were minimised by replacing them with defined lists; data entry was simplified, only including data relevant to the purposes of the registry; detailed instructions were given to residents about filling in data in the registry. In addition, the data entered is constantly evaluated so that the resident makes necessary corrections. All this makes it possible to bring greater uniformity to the collection of information.7
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Fig. 1 – General list.
Fig. 2 – Registration area for new procedures.
3
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1
2
3 EMERGENCY
4
5
6 ELECTIVE
PAEDIATRICS NEUROTRAUMA VASCULAR PERIPHERAL ONCOLOGY SPINE EPILEPSY FUNCTIONAL AND STEREOTACTIC
Fig. 3 – Neurosurgery specialisation programme.
The registry is made up of six main areas: • General list. This is the login area of our registry; here we find a list as a report of all patients who have been treated surgically by our department. It includes general patient data, procedure data and the name of the teacher and residents who participated in the procedure and their specific role (Fig. 1). • Area for recording new procedures. The resident will record each new procedure in which he or she has participated; subsequently, the teacher in charge must review and approve the record, being able to make corrections and observations on different aspects of the procedure. Patient identification data, medical history, details of the surgical procedure, teacher in charge, residents participating in the procedure and their specific role will be collected. In addition, areas are included where relevant images and videos of the case report will be stored (i.e. preoperative, transoperative and postoperative images, video and imaging studies) (Fig. 2). • Analysis and procedure editing area. Each of the stored procedures can be subsequently reviewed and edited by the user, registering the name of the user who makes the modification, if any. It also allows for the review and analysis of the data that have been recorded in each of the procedures. • Residents’ area. In the evolution of resident learning it is important to have a record of how many and which procedures they have performed throughout their specialisation programme. This area seeks to fulfil this need, reporting the number of procedures performed throughout their training or in certain academic periods in each of the roles in which the resident can participate. In addition, each resident can check the number of times they have participated in procedures of different surgical categories and in specific procedures according to each of the roles. • Teachers’ area. In the same way as in the residents’ area, teachers can consult the general number of procedures for which they have been responsible, and the specific number according to the surgical category and the surgical procedure. • Department statistics. In this area, we can observe the number of surgical procedures that have been performed during the year; in addition, it shows the number of procedures that have been carried out by the department according to the
surgical category, the surgical procedure and the surgical diagnosis. A total of 13 residents were registered in the neurosurgery specialisation programme of the Neurosurgery and Endovascular Neurological Therapy Department at the Hospital Universitario “Dr. José Eleuterio González” UANL in the period from February 2018 to July 2018. During this period, the procedures in which each resident participated and the role he/she played were documented in the “Electronic Neurosurgical Registry”. Residents who withdrew from the specialisation programme were excluded.
Results The “Electronic Registry of Neurosurgical Procedures” has been in operation for six months. The initial development included a station and a mobile device, currently each resident and teacher can enter from their mobile devices and personal computers through an individualised account. A total of 530 procedures performed in the period from February to July 2018 have been recorded. During this six-month period, approximately three procedures were performed per day. A total of 73.1% (387) of the surgical procedures were performed in adult patients (16 years of age or older) and 27% (143) in paediatric patients. Of the total procedures, 33% (175) were due to craniocerebral trauma, 20% (106) due to hydrocephalus and congenital malformations, 12.1% (64) due to vascular diseases, 10.9% (58) due to intracranial neoplasms and 10.6% (56) due to diseases of the spine; the remaining percentage, 13.4% (71), is subdivided into the categories of epilepsy surgery, intracranial infection, intracranial neoplasia, peripheral nerve and stereotactic and functional surgery. In adult patients, the most common surgical categories are: craniocerebral trauma (37%, 196), vascular diseases (14%, 74) and hydrocephalus and congenital malformations (12.1%, 64). In paediatric patients, the most frequently observed surgical categories are: hydrocephalus and congenital malformations (47%, 249), craniocerebral trauma (22%), spine procedures (10%, 53) and intracranial neoplasms (10%, 53). Our institution’s neurosurgery specialisation programme is divided into two large areas: for the first four years the resident participates mainly in emergency procedures where he
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Table 1 – Surgeries per resident according to the learning role. Year I II III IV V VI
See one
Do one
9 (100%) 13 (11.8%) 10 (16.6%) 16 (44.6%) 37 (77.8%) 14 (28.6%)
0 (0%) 94 (88%) 49 (79.5%) 12 (34.7%) 6 (12.7%) 35 (69.8%)
Teach one 0 (0%) 0 (0%) 2 (3.9%) 7 (20.8%) 5 (9.5%) 1 (1.5%)
100.0% 90.0% 80.0% 70.0% 60.0% SEE ONE DO ONE
50.0%
TEACH ONE
40.0% 30.0% 20.0% 10.0% 0.0%
I
II
III
IV
V
5
and the different forms of treatment of these conditions. He or she should be able to advise and educate his or her patients about the risks and benefits of a specific treatment and should be able and in a position to refer the patient, if he or she does not perform the respective procedure with a “proper routine”, to a more experienced colleague or department.9 An important question is, how many procedures in each category should be performed during training to achieve a “proper routine” and the desired competence? Since each resident has different skills, ambitions and abilities, a range of competence must be stipulated. Thus, the resident must present at least a minimum level of competence in a given area, although he or she may show a much higher level in another area.9 The provision of adequate surgical exposure to residents should be a key performance indicator for training programmes.10 It is essential that such a programme be combined with a consistent method to assess the resident’s progress; it must be determined if he or she has reached the required level of knowledge and clinical and surgical skills at each stage of the training.1 An adequate neurosurgical registry will help to recognise this process, identifying the roles and complexity of the surgical procedure in which the resident participates.
VI
Fig. 4 – Surgeries per resident according to the learning role.
or she acquires the necessary skills to subsequently make a gradual step to carrying them out, during the last two years, the resident learns more complex elective procedures (Fig. 3). Gradual learning of the resident during his or her progress in the specialisation programme is observed in the analysis of the Registry data (Table 1 and Fig. 4). Learning by observation and supervised practice (“see one”) are mainly carried out in the first and fifth year of residence, the years when the resident begins his or her training programme in the area of emergency and elective surgeries, respectively. Subsequently, the resident is able to perform surgeries independently (“do one”), in the emergency department, during the second and third year; and in the elective surgery block, until the sixth year. The resident is able to instruct other less experienced surgeons (“teach one”) in the fourth year since the resident supported by senior residents and programme teachers is the one who teaches basic emergency procedures to less experienced residents. In the elective block, the teacher is in charge of teaching the procedures.
Discussion A large number of studies have shown better results in patients operated on by surgeons who frequently perform a certain procedure.8 Experience through repetition improves ability, increases confidence and provides greater exposure to anatomical variants and potential complications.1 During his or her training, a resident must see enough patients to be able to recognise the diagnostic procedure, differential diagnoses
Conclusions The “Electronic Neurosurgical Registry” is an innovative technological tool that supports the fields of assistance, teaching and research in the Neurosurgery and Endovascular Neurological Therapy Department of the Hospital Universitario “Dr. José Eleuterio González” UANL. Thanks to the statistics that this new tool provides automatically, it is possible to know exactly the number of patients who have undergone surgery at a given time, which provides valuable information for the proper management of resources, thus improving the quality of care. In addition to the registry described, there is only documentation in the literature about a similar tool used in the field of training specialists in neurosurgery: the European Neurosurgical Registry-UEMS/EANS1,9,11 ; however, there is no evidence that in Mexico any surgical specialty programme uses a tool to monitor and evaluate the educational progress of residents. Our registry was designed to comply with the indicators and standards for evaluation and accreditation of national and international bodies and agencies; such as the Consejo Nacional de Cirugía Neurológica, A.C. [National Council of Neurological Surgery], the Programa Nacional de Posgrados de Calidad [National Quality Postgraduate Programme] (PNPC), the European Association of Neurosurgical Societies (EANS) and the Accreditation Council for Graduate Medical Education (ACGME), which makes it an ideal mechanism to institutionally evaluate the performance of the residency programme and for the evaluation of residents by national and international organisations. The “Electronic Registry of Neurosurgical Procedures” evaluates the quality of the residency programme in neurosurgery, analysing important aspects in the learning process of each of the residents. The data obtained enable areas of opportunity
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in their training to be identified, which allows for the development of strategies for continuous improvement in the training of competent neurosurgeons.
4.
Conflicts of interest
5.
None declared.
6.
Acknowledgements To the Department of Neurosurgery and Endovascular Neurological Therapy of the Hospital Universitario “Dr. José Eleuterio González”, UANL.
7. 8.
references 9. 1. Lindsay KW. A structured neurosurgical training plan and the neurosurgical logbook in the UK. Acta Neurochir Suppl. 2004;90:51–7. 2. Marcus H, Vakharia V, Kirkman MA, Murphy M, Nandi D. Practice makes perfect? The role of simulation-based deliberate practice and script-based mental rehearsal in the acquisition and maintenance of operative neurosurgical skills. Neurosurgery. 2013;72 Suppl. 1:124–30. 3. Beasley SW, McBride C, Pearson ML. Use of the operative logbook to monitor trainee progress, and evaluate operative
10.
11.
supervision provided by accredited training posts. Surgeon. 2011;9 Suppl. 1:S14–5. Merry C, Goodall-Wilson D, Guest G, Papas C, Selvidge J, Watters DA. The surgical trainee log we need: minimum of work, maximum of output. ANZ J Surg. 2006;76:185–9. Watters DA, Green AJ, van Rij A. Requirements for trainee logbooks. ANZ J Surg. 2006;76:181–4. NORMA Oficial Mexicana. NOM-024-SSA3-2012. In: Comité Consultivo Nacional de Normalización de Innovación Desarrollo Tecnologías e Información en Salud, ed. Sistemas de información de registro electrónico para la salud. Intercambio de información en salud. Vol DCCX: 23. Matutino ed. Secretaría de Gobernación: Diario Oficial de la Federación; 2012. p. 79–96. Achuthan R, Grover K, MacFie J. A critical evaluation of the electronic surgical logbook. BMC Med Educ. 2006;6:15. Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, et al. Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg. 2002;236:583–92. Reulen HJ, European Union of Medical Specialist, European Association of Neurosurgical Societies. The European Neurosurgical Log-Book (UEMS/EANS). Acta Neurochir Suppl. 2004;90:59–66. Lonergan PE, Mulsow J, Tanner WA, Traynor O, Tierney S. Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook. BMC Med Educ. 2011;11:70. Eroes CA, Barth C, Tonn JC, Reulen HJ. The revised European neurosurgical electronic logbook of operations. Acta Neurochir (Wien). 2008;150:195–8.
NEUROCIRUGÍA www.elsevier.es/neurocirugia
Special article
Mobile application to analyse surgical experience夽 Everardo Garcia-Estrada, Jesús A. Morales-Gómez ∗ , Miriam Delgado-Brito, Ari A. Martínez-López, Luis E. Flores-Huerta, Ángel R. Martínez-Ponce de León Servicio de Neurocirugía y Terapia Endovascular Neurológica, Hospital Universitario Dr. José Eleuterio González, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To quantify the surgical experience acquired by residents in the neurosurgery
Received 25 September 2018
specialisation programme over a 6-month period.
Accepted 9 September 2019
Materials and methods: A total of 13 residents enrolled in the neurosurgery specialisation
Available online xxx
programme from February 2018 to July 2018. Over this period, the procedures residents
Keywords:
Register. Residents who withdrew from the specialisation programme were excluded.
Surgical register
Results: A total of 530 procedures were performed during the study period. Observational
were involved in and the role they played were documented in the Electronic Neurosurgical
Neurosurgery
learning and supervised practice are conducted primarily in the first and fifth years of res-
Supervision
idence, during which residents begin their training in emergency and elective surgeries,
Surgical teaching
respectively. Residents are then able to independently perform emergency surgeries during
Resident
the second and third years, and elective surgeries in the sixth year. Residents are able to
Electronic register
instruct less experienced surgeons in the fourth year. Conclusions: The Electronic Neurosurgical Register is an innovative technological tool that supports the fields of care, teaching and research. It records the exact number of patients who have undergone surgery at a particular time, providing valuable information for the proper management of resources. The data obtained can be used to identify areas of opportunity in the training of residents, facilitating the development of continuous improvement strategies in the training of competent neurosurgeons. ˜ ˜ S.L.U. All rights © 2019 Sociedad Espanola de Neurocirug´ıa. Published by Elsevier Espana, reserved.
DOI of original article: https://doi.org/10.1016/j.neucir.2019.09.001. Please cite this article as: Garcia-Estrada E, Morales-Gómez JA, Delgado-Brito M, Martínez-López AA, Flores-Huerta LE, Martínez-Ponce de León ÁR. Aplicación móvil para el análisis de la experiencia quirúrgica. Neurocirugia. 2019. https://doi.org/10.1016/j.neucir.2019.09.001 ∗ Corresponding author. E-mail address: [email protected] (J.A. Morales-Gómez). ˜ ˜ S.L.U. All rights reserved. 2529-8496/© 2019 Sociedad Espanola de Neurocirug´ıa. Published by Elsevier Espana, 夽
NEUCIE-399; No. of Pages 6
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n e u r o c i r u g i a . 2 0 1 9;x x x(x x):xxx–xxx
Aplicación móvil para el análisis de la experiencia quirúrgica r e s u m e n Palabras clave:
Objetivo: Cuantificar la experiencia quirúrgica obtenida por los residentes del programa de
Registro quirúrgico
especialización en neurocirugía durante un periodo de 6 meses.
Neurocirugía
Material y método: Un total de 13 residentes se registraron en el programa de especialización
Supervisión
en neurocirugía en el periodo de febrero a julio de 2018. Durante este periodo se docu-
˜ quirúrgica Ensenanza
mentaron en el Registro Neuroquirúrgico Electrónico los procedimientos en los que cada
Residente
˜ Los residentes que se retiraron del programa residente participó y el rol que desempenó.
Registro electrónico
fueron excluidos. Resultados: Se realizaron 530 procedimientos en el periodo de estudio. El aprendizaje por ˜ de observación y la práctica tutelada se realizan principalmente en el primer y quinto ano residencia, periodos durante los cuales el residente comienza su aprendizaje en el área cirugías de urgencias y electivas, respectivamente. Posteriormente es capaz de realizar ˜ y cirugías de manera autónoma, en el bloque de urgencias, durante el segundo y tercer ano; ˜ El residente es capaz de instruir a cirujanos en el bloque de cirugías electivas, en el sexto ano. ˜ menos experimentados en el cuarto ano. Conclusiones: El Registro Neuroquirúrgico Electrónico es una herramienta tecnológica innovadora que apoya en los campos de asistencia, docencia e investigación. Permite conocer con exactitud la cantidad de pacientes que han sido intervenidos quirúrgicamente en un determinado momento, lo cual brinda información valiosa para el manejo adecuado de recursos. Los datos obtenidos permiten identificar áreas de oportunidad en el entrenamiento de los residentes, lo que permite el desarrollo de estrategias para la mejora continua en la formación de neurocirujanos competentes. ˜ ˜ S.L.U. Todos © 2019 Sociedad Espanola de Neurocirug´ıa. Publicado por Elsevier Espana, los derechos reservados.
Introduction The neurosurgery training programme aims to produce surgeons capable of independent practice. The methodology in the training to train competent surgeons is similar among institutions; however, even in the same institution there are differences in the degree of surgical experience acquired by each resident.1 To become competent in neurosurgery, postgraduate students must learn to manage nerve tissue in an appropriate, gentle and precise manner. Historically, skills have been acquired with the premise of “See one, do one, teach one”.2 Novice residents face surgical procedures for the first time and rely heavily on close supervision by a mentor.2 Gradually, the resident will acquire skills necessary for independent practice2 and thus will have the ability to perform certain procedures on his or her own. Analysing the number of procedures that each resident has performed in the different roles will identify those who learn slower and, therefore, require additional support in their training.3 An easy-to-use portable database4 that automatically generates reports covering the educational and quality aspects of the resident’s experience5 is useful for this analysis. With this objective, the Neurosurgery and Endovascular Neurological Therapy Department of the Hospital Universitario “Dr. José Eleuterio González” UANL [UANL University Hospital “Dr. José Eleuterio González”] developed a mobile application: “Electronic Neurosurgical Registry” that can be used with a
computer or with a mobile device compatible with the programme and an Internet connection. The objective of this study was to quantify the surgical experience obtained by residents of the neurosurgery specialisation programme over a period of six months. This information can help us identify deficiencies; not only of individual training, but also within the institutions and the neurosurgery specialisation programme in order to maintain the quality of surgical training.
Material and methods The “Electronic Neurosurgical Registry” is a technological solution generated to share information that guarantees patients’ confidentiality as well as the integrity and reliability of clinical information; in addition, it establishes pertinent and adequate security measures, in order to avoid the illegal or illegitimate use of the information.6 For the development of this tool, recommendations made after the analysis of other electronic registries were taken into account. Fields that allow free text were minimised by replacing them with defined lists; data entry was simplified, only including data relevant to the purposes of the registry; detailed instructions were given to residents about filling in data in the registry. In addition, the data entered is constantly evaluated so that the resident makes necessary corrections. All this makes it possible to bring greater uniformity to the collection of information.7
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Fig. 1 – General list.
Fig. 2 – Registration area for new procedures.
3
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1
2
3 EMERGENCY
4
5
6 ELECTIVE
PAEDIATRICS NEUROTRAUMA VASCULAR PERIPHERAL ONCOLOGY SPINE EPILEPSY FUNCTIONAL AND STEREOTACTIC
Fig. 3 – Neurosurgery specialisation programme.
The registry is made up of six main areas: • General list. This is the login area of our registry; here we find a list as a report of all patients who have been treated surgically by our department. It includes general patient data, procedure data and the name of the teacher and residents who participated in the procedure and their specific role (Fig. 1). • Area for recording new procedures. The resident will record each new procedure in which he or she has participated; subsequently, the teacher in charge must review and approve the record, being able to make corrections and observations on different aspects of the procedure. Patient identification data, medical history, details of the surgical procedure, teacher in charge, residents participating in the procedure and their specific role will be collected. In addition, areas are included where relevant images and videos of the case report will be stored (i.e. preoperative, transoperative and postoperative images, video and imaging studies) (Fig. 2). • Analysis and procedure editing area. Each of the stored procedures can be subsequently reviewed and edited by the user, registering the name of the user who makes the modification, if any. It also allows for the review and analysis of the data that have been recorded in each of the procedures. • Residents’ area. In the evolution of resident learning it is important to have a record of how many and which procedures they have performed throughout their specialisation programme. This area seeks to fulfil this need, reporting the number of procedures performed throughout their training or in certain academic periods in each of the roles in which the resident can participate. In addition, each resident can check the number of times they have participated in procedures of different surgical categories and in specific procedures according to each of the roles. • Teachers’ area. In the same way as in the residents’ area, teachers can consult the general number of procedures for which they have been responsible, and the specific number according to the surgical category and the surgical procedure. • Department statistics. In this area, we can observe the number of surgical procedures that have been performed during the year; in addition, it shows the number of procedures that have been carried out by the department according to the
surgical category, the surgical procedure and the surgical diagnosis. A total of 13 residents were registered in the neurosurgery specialisation programme of the Neurosurgery and Endovascular Neurological Therapy Department at the Hospital Universitario “Dr. José Eleuterio González” UANL in the period from February 2018 to July 2018. During this period, the procedures in which each resident participated and the role he/she played were documented in the “Electronic Neurosurgical Registry”. Residents who withdrew from the specialisation programme were excluded.
Results The “Electronic Registry of Neurosurgical Procedures” has been in operation for six months. The initial development included a station and a mobile device, currently each resident and teacher can enter from their mobile devices and personal computers through an individualised account. A total of 530 procedures performed in the period from February to July 2018 have been recorded. During this six-month period, approximately three procedures were performed per day. A total of 73.1% (387) of the surgical procedures were performed in adult patients (16 years of age or older) and 27% (143) in paediatric patients. Of the total procedures, 33% (175) were due to craniocerebral trauma, 20% (106) due to hydrocephalus and congenital malformations, 12.1% (64) due to vascular diseases, 10.9% (58) due to intracranial neoplasms and 10.6% (56) due to diseases of the spine; the remaining percentage, 13.4% (71), is subdivided into the categories of epilepsy surgery, intracranial infection, intracranial neoplasia, peripheral nerve and stereotactic and functional surgery. In adult patients, the most common surgical categories are: craniocerebral trauma (37%, 196), vascular diseases (14%, 74) and hydrocephalus and congenital malformations (12.1%, 64). In paediatric patients, the most frequently observed surgical categories are: hydrocephalus and congenital malformations (47%, 249), craniocerebral trauma (22%), spine procedures (10%, 53) and intracranial neoplasms (10%, 53). Our institution’s neurosurgery specialisation programme is divided into two large areas: for the first four years the resident participates mainly in emergency procedures where he
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Table 1 – Surgeries per resident according to the learning role. Year I II III IV V VI
See one
Do one
9 (100%) 13 (11.8%) 10 (16.6%) 16 (44.6%) 37 (77.8%) 14 (28.6%)
0 (0%) 94 (88%) 49 (79.5%) 12 (34.7%) 6 (12.7%) 35 (69.8%)
Teach one 0 (0%) 0 (0%) 2 (3.9%) 7 (20.8%) 5 (9.5%) 1 (1.5%)
100.0% 90.0% 80.0% 70.0% 60.0% SEE ONE DO ONE
50.0%
TEACH ONE
40.0% 30.0% 20.0% 10.0% 0.0%
I
II
III
IV
V
5
and the different forms of treatment of these conditions. He or she should be able to advise and educate his or her patients about the risks and benefits of a specific treatment and should be able and in a position to refer the patient, if he or she does not perform the respective procedure with a “proper routine”, to a more experienced colleague or department.9 An important question is, how many procedures in each category should be performed during training to achieve a “proper routine” and the desired competence? Since each resident has different skills, ambitions and abilities, a range of competence must be stipulated. Thus, the resident must present at least a minimum level of competence in a given area, although he or she may show a much higher level in another area.9 The provision of adequate surgical exposure to residents should be a key performance indicator for training programmes.10 It is essential that such a programme be combined with a consistent method to assess the resident’s progress; it must be determined if he or she has reached the required level of knowledge and clinical and surgical skills at each stage of the training.1 An adequate neurosurgical registry will help to recognise this process, identifying the roles and complexity of the surgical procedure in which the resident participates.
VI
Fig. 4 – Surgeries per resident according to the learning role.
or she acquires the necessary skills to subsequently make a gradual step to carrying them out, during the last two years, the resident learns more complex elective procedures (Fig. 3). Gradual learning of the resident during his or her progress in the specialisation programme is observed in the analysis of the Registry data (Table 1 and Fig. 4). Learning by observation and supervised practice (“see one”) are mainly carried out in the first and fifth year of residence, the years when the resident begins his or her training programme in the area of emergency and elective surgeries, respectively. Subsequently, the resident is able to perform surgeries independently (“do one”), in the emergency department, during the second and third year; and in the elective surgery block, until the sixth year. The resident is able to instruct other less experienced surgeons (“teach one”) in the fourth year since the resident supported by senior residents and programme teachers is the one who teaches basic emergency procedures to less experienced residents. In the elective block, the teacher is in charge of teaching the procedures.
Discussion A large number of studies have shown better results in patients operated on by surgeons who frequently perform a certain procedure.8 Experience through repetition improves ability, increases confidence and provides greater exposure to anatomical variants and potential complications.1 During his or her training, a resident must see enough patients to be able to recognise the diagnostic procedure, differential diagnoses
Conclusions The “Electronic Neurosurgical Registry” is an innovative technological tool that supports the fields of assistance, teaching and research in the Neurosurgery and Endovascular Neurological Therapy Department of the Hospital Universitario “Dr. José Eleuterio González” UANL. Thanks to the statistics that this new tool provides automatically, it is possible to know exactly the number of patients who have undergone surgery at a given time, which provides valuable information for the proper management of resources, thus improving the quality of care. In addition to the registry described, there is only documentation in the literature about a similar tool used in the field of training specialists in neurosurgery: the European Neurosurgical Registry-UEMS/EANS1,9,11 ; however, there is no evidence that in Mexico any surgical specialty programme uses a tool to monitor and evaluate the educational progress of residents. Our registry was designed to comply with the indicators and standards for evaluation and accreditation of national and international bodies and agencies; such as the Consejo Nacional de Cirugía Neurológica, A.C. [National Council of Neurological Surgery], the Programa Nacional de Posgrados de Calidad [National Quality Postgraduate Programme] (PNPC), the European Association of Neurosurgical Societies (EANS) and the Accreditation Council for Graduate Medical Education (ACGME), which makes it an ideal mechanism to institutionally evaluate the performance of the residency programme and for the evaluation of residents by national and international organisations. The “Electronic Registry of Neurosurgical Procedures” evaluates the quality of the residency programme in neurosurgery, analysing important aspects in the learning process of each of the residents. The data obtained enable areas of opportunity
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n e u r o c i r u g i a . 2 0 1 9;x x x(x x):xxx–xxx
in their training to be identified, which allows for the development of strategies for continuous improvement in the training of competent neurosurgeons.
4.
Conflicts of interest
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None declared.
6.
Acknowledgements To the Department of Neurosurgery and Endovascular Neurological Therapy of the Hospital Universitario “Dr. José Eleuterio González”, UANL.
7. 8.
references 9. 1. Lindsay KW. A structured neurosurgical training plan and the neurosurgical logbook in the UK. Acta Neurochir Suppl. 2004;90:51–7. 2. Marcus H, Vakharia V, Kirkman MA, Murphy M, Nandi D. Practice makes perfect? The role of simulation-based deliberate practice and script-based mental rehearsal in the acquisition and maintenance of operative neurosurgical skills. Neurosurgery. 2013;72 Suppl. 1:124–30. 3. Beasley SW, McBride C, Pearson ML. Use of the operative logbook to monitor trainee progress, and evaluate operative
10.
11.
supervision provided by accredited training posts. Surgeon. 2011;9 Suppl. 1:S14–5. Merry C, Goodall-Wilson D, Guest G, Papas C, Selvidge J, Watters DA. The surgical trainee log we need: minimum of work, maximum of output. ANZ J Surg. 2006;76:185–9. Watters DA, Green AJ, van Rij A. Requirements for trainee logbooks. ANZ J Surg. 2006;76:181–4. NORMA Oficial Mexicana. NOM-024-SSA3-2012. In: Comité Consultivo Nacional de Normalización de Innovación Desarrollo Tecnologías e Información en Salud, ed. Sistemas de información de registro electrónico para la salud. Intercambio de información en salud. Vol DCCX: 23. Matutino ed. Secretaría de Gobernación: Diario Oficial de la Federación; 2012. p. 79–96. Achuthan R, Grover K, MacFie J. A critical evaluation of the electronic surgical logbook. BMC Med Educ. 2006;6:15. Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, et al. Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg. 2002;236:583–92. Reulen HJ, European Union of Medical Specialist, European Association of Neurosurgical Societies. The European Neurosurgical Log-Book (UEMS/EANS). Acta Neurochir Suppl. 2004;90:59–66. Lonergan PE, Mulsow J, Tanner WA, Traynor O, Tierney S. Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook. BMC Med Educ. 2011;11:70. Eroes CA, Barth C, Tonn JC, Reulen HJ. The revised European neurosurgical electronic logbook of operations. Acta Neurochir (Wien). 2008;150:195–8.