Real heart surgery is better and safer after simulation training, studies show

Cardiothoracic surgery residents who received simulation training—instead of surgical training exclusively in the operating room—improved in all surgical skills evaluated, with perfect or near perfect performance, researchers reported. The residents were also better prepared to manage adverse events in the heat of surgery, according to findings of two related studies published August 25, 2016 in The Annals of Thoracic Surgery.

“Simulation training should create better surgeons who are trained much more efficiently,” said Richard H. Feins, MD, Professor in the Division of Cardiothoracic Surgery at the University of North Carolina at Chapel Hill, NC, who led one of the studies.

“This type of learning allows surgery residents to develop their knowledge, skills, and confidence, before going into the operating room, thus protecting patients from unnecessary risks,” Dr. Feins added.

Surgery residents have traditionally been taught technical skills under the apprentice model, in which they learn in the operating room by performing real operations on real patients under supervision.

But the modern operating room is too fast-paced and has too many competing priorities to be the only place to train residents, Dr. Feins noted. A simulation-based curriculum can enhance and facilitate training by avoiding the limitations of the operating room—and complementing the traditional apprentice training model in surgery.

Unlike the operating room, the simulated surgery environment allows learning and re-learning skills as often as required to correct mistakes. This provides the opportunity for residents to fine-tune skills and gain confidence, in an effort to optimize clinical outcomes.

“In the simulation environment, the essentials of producing masters—deliberate practice and component task training—can be employed,” Dr. Feins said. “One would never expect to produce an outstanding basketball team if the players could only develop their skills during a game. But that is essentially what the apprentice model in surgery does. We have shown there is a better way.”

These studies were performed by the Cardiac Surgery Simulation Consortium, a group of leaders from eight major cardiothoracic surgery residency programs in the United States.

For the first of these studies, the Consortium developed a rigorous, 39-session curriculum that included simulation training modules for three commonly performed cardiac surgery procedures (cardiopulmonary bypass, coronary artery bypass grafting, and aortic valve replacement) and three adverse events (massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function).

The six modules were designed with basic simulation principles in mind—repetition, deliberate practice, supervision, progressive simulation complexity, formative feedback, and summative assessment. The simulations ranged from simple plastic models to real tissue and pig hearts that duplicated living patients undergoing surgery.

After completing simulation training, 85% of residents and the entire faculty (100%) reported feeling more comfortable and confident with the resident skillset and performance in the operating room. The experience also helped residents and faculty develop an improved rapport and confidence in each other. Both residents and faculty were enthusiastic about training in adverse events and crisis management.

“The rapport I had with the residents was exponentially improved,” said study leader Nahush A. Mokadam, MD, Co-Director of Heart Transplantation at University of Washington Medical Center, Seattle, WA.

“I had practiced with the residents in the simulation lab and they had proved to me time and again that they knew the steps and that they understood the principles of the operation,” Dr. Mokadam added. “So when we were in the operating room, my confidence level in those residents was extremely high because they had already proved to me that they could do it.”

The second study evaluated the residents’ training skills after participating in the new curriculum. The 27 residents who participated demonstrated improvement in all surgical skills that were evaluated, with perfect or near perfect performance after about 110 hours of total simulation training per resident. The per-repetition analyses from the study showed a clear relationship between repetition of a task and improvement in performance.

“Simulation-based training in adverse events could well prove life-saving,” Dr. Feins said. “This training has the ability to decrease the number of adverse outcomes that occur and to minimize the ramifications of those events. This should result in better outcomes for patients, as well as lower costs and improved efficiency.”

The new curriculum is now available from the Thoracic Surgery Directors Association. In addition, the Consortium will also train faculty members at other residency programs on how to use the curriculum.

“The simulation-based training curriculum will continue to evolve and expand,” Dr. Feins said. “This model for training is also being adopted for training in other parts of cardiothoracic surgery such as robotic lobectomy. We hope that it will be an integral part of every resident’s experience in the not so distant future.”

Dr. Feins and other authors disclosed a financial relationship with KindHeart Inc. Dr. Mokadam disclosed a financial relationship with Thoratec Corporation, HeartWare Inc., SynCardia Systems Inc., and St. Jude Medical.