TY - JOUR
T1 - Fasciotomy Improvement Through Recognition of Errors Course
T2 - A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance
AU - Kucera, Walter
AU - Nealeigh, Matthew
AU - Franklin, Brenton
AU - Bowyer, Mark
AU - Sweeney, W. Brian
AU - Ritter, E. Matthew
N1 - Funding Information:
Disclosures: Dr. Ritter receives royalties and research support from the Henry M. Jackson Foundation for the Advancement of Military Medicine, but this relationship had no impact on the conduct or design of the above work. Disclosures: Dr. Ritter receives royalties and research support from the Henry M. Jackson Foundation for the Advancement of Military Medicine, but this relationship had no impact on the conduct or design of the above work.
Publisher Copyright:
© 2019
PY - 2019/9/1
Y1 - 2019/9/1
N2 - Background: Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training. Methods: In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula. Results: Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments Conclusions: Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.
AB - Background: Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training. Methods: In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula. Results: Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments Conclusions: Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.
KW - Education
KW - Error-management training
KW - Error-recognition training
KW - Fasciotomy
KW - Medical Knowledge
KW - Patient Care
KW - Practice-Based Learning and Improvement
UR - http://www.scopus.com/inward/record.url?scp=85063251463&partnerID=8YFLogxK
U2 - 10.1016/j.jsurg.2019.03.003
DO - 10.1016/j.jsurg.2019.03.003
M3 - Article
C2 - 30910499
AN - SCOPUS:85063251463
SN - 1931-7204
VL - 76
SP - 1303
EP - 1308
JO - Journal of Surgical Education
JF - Journal of Surgical Education
IS - 5
ER -