key: cord-0963954-nrwfxcsc
authors: Takahashi, Kenichiro; Tanaka, Chiharu; Numaguchi, Ryosuke; Kuroda, Yoshinori; Nemoto, Hiroko; Yoshino, Kunihiko; Noda, Mika; Inoue, Yoshinori; Wada, Kumiko
title: Remote Simulator Training of Coronary Artery Bypass Grafting during the COVID-19 Pandemic
date: 2021-08-21
journal: JTCVS Open
DOI: 10.1016/j.xjon.2021.08.019
sha: 4bae15c7ec7f5301da12678ff684d09b7a17a82f
doc_id: 963954
cord_uid: nrwfxcsc

Objectives The coronavirus disease 2019 (COVID-19) pandemic presents in-person exposure risk during surgical education. We aimed to validate the feasibility of fully remote faculty-supervised surgical training sessions focused on coronary artery bypass grafting using a synthetic simulator and online video-chat software. Methods This observational study organized 24 sessions of 2-hour remote training. Each session involved three trainees, one faculty, and one host. A total of 70 trainees and 24 faculties were enrolled. The participants joined the remote sessions via online video-chat, and performed focused training in coronary artery anastomosis using a commercially available simulator. A survey was conducted to validate the feasibility of the remote sessions. Performance improvement of the trainees who repeatedly participated (n = 13) were analyzed comparing initial and final scores of various performance indicators. Results All trainees and faculties were satisfied with the efficacy of the remote session. Additionally, most trainees (79%) and faculties (95%) agreed that the remote training sessions were equivalent to conventional on-site training seminars. A significant improvement between initial and last sessions was observed in the scoring components of near side (3.4 ± 1.0 vs. 4.1 ± 0.9; P = 0.02), far side (3.3 ± 0.8 vs. 3.9 ± 0.8; P = 0.03), external appearance (3.5 ± 0.8 vs. 4.2 ± 0.7; P = 0.01), and internal appearance (2.8 ± 0.9 vs. 4.0 ± 0.9; P = 0.004) Conclusions Faculty-supervised remote surgical training sessions were executed with satisfactory results. This methodology may have important implications for surgical education during the COVID-19 pandemic.

In recent years, there has been a shift from traditional Halstedian methods toward more 94 simulation-based education for developing the surgical skills of trainees. 1 Young cardiac 95 surgeons have less opportunities to operate on real patients in the current clinical 96 environment because of the ethical concerns and more complex procedures performed on 97 higher-risk patients. [2] [3] [4] Trainees are therefore largely trained in the laboratory with 98 simulation-based education and allowed to participate in graduated performance of 99 procedures on patients. 3 Considering the sentiment on this issue, the Japanese Board of 100 Cardiovascular Surgery committee has started to obligate off-the-job training (OFFJT) for 101 board certification, besides a board examination and inspection of surgical experience, since 102 2017. 5 They defined OFFJT as faculty-supervised surgical skill acquisition using simulators 103 (e.g. synthetic vessel simulators, explanted porcine heart, and animal surgical laboratory), as 104 opposed to patients. In response to this, the Japanese Society for Cardiovascular Surgery 105 (JSCVS) Under-Forty (U-40), which is an official committee consisting of Japanese 106 cardiovascular surgeons under the age of 40, has recently engaged in holding nationwide 107 simulation-based surgical training seminars every few years. 6 A total of more than 300 108 cardiovascular trainees have participated in the JSCVS U-40 seminars each year while more 109 than 100 faculty surgeons have participated as instructors. 110 bypass grafting (CABG) using a synthetic coronary vessel simulator, YOUCAN (EBM 119 Corporation, Tokyo, Japan), and the online video-chat software, Zoom (Zoom Video 120

Communications, Inc., California, USA). This study evaluated the feasibility of 121 faculty-supervised focused training in coronary artery anastomosis in a completely isolated 122 environment with no risk of close contact and viral infection. 123 J o u r n a l P r e -p r o o f This observational study was designed to validate the feasibility of fully remote 126 faculty-supervised surgical training sessions in coronary artery anastomosis using YOUCAN 127 and Zoom. This study also examined the utility of our novel remote surgical training method 128 using a participant questionnaire and trainee skill evaluation. Nippon Medical School 129

Institutional Review Board approved this observational study (A-2020-045) on May 10, 2021. 130

All participants agreed to the research and publication of this study with written consents. 131 132

From September to December 2020, JSCVS U-40 committee held 24 remote 134 simulation-based surgical skill training sessions focused on coronary artery anastomosis. 135

Each training session was held via Zoom from 5pm to 7pm on Saturday or Sunday, which is 136 a suitable time frame for OFFJT for cardiovascular surgeons in Japan. To achieve 137 high-quality remote training session directly supervised by a dedicated faculty surgeon with 138 individual feedback, the number of trainees was limited to three per session ( Figure 1 ). 139

Trainees, less than 40 years old, who were dedicated or would be dedicated to 140 cardiovascular surgery in Japan, were recruited via the website of JSCVS U-40. They were 141 required to enter the necessary information (e.g., full name, institution, address, telephone 142 number, email address, postgraduate years, JSCVS membership identification number, and 143 preferred date to participate) into the application form to join the remote training session. 144

Google Forms (Google, California, USA) was used for the online application. Trainees were 145 welcomed for either single or multiple participation at their own will. Faculties were 146 recruited from attending surgeons who belong to leading institutions all over Japan. No 147 reward was provided for the faculties' participation.

A week before the predetermined date of the session, participants received the following 151 instruments shipped to their home; YOUCAN (EBM Corporation, Tokyo, Japan), Anasthon 152 A-1 Kit (EBM Corporation, Tokyo, Japan), a Castroviejo needle holder, micro forceps, 153 coronary scissors, 7/0 monofilament polypropylene sutures (Prolene, Ethicon Inc; Johnson & 154 Johnson, NJ, USA), and a disposable vessel knife ( Figure 2A ). YOUCAN is a commercially 155 available high-fidelity silicone vascular model reproducing the fragile multilayered structure 156 of native coronary artery and internal thoracic artery grafts. The inner diameter of vessel 157 models is 2 mm. Anasthon A-1 Kit is the plastic-made foldable base of YOUCAN with a 158 lighting system. This kit was developed for daily practice and remote training sessions using 159 YOUCAN and intended to use for not only fixation of YOUCAN on its base ( Figure 2B After the demonstration, a faculty surgeon rated each trainee's performance according to a 188 5-point scoring scale (Table 1) , modified from the Objective Structured Assessment of 189 Technical Skills (OSATS). 2, 4, 8, 9 This performance rating system was designed to notify 190 trainees of their weaknesses and ways to improve their techniques at the end of the session. 191

Given the formative feedback with rating scores, trainees were encouraged to perform further 192 free practice to improve their techniques by themselves after the session. Performance 193 improvement of the trainees who participated multiple times in these sessions were analyzed 194 statistically comparing the scores between their initial and last session. 195 agreed or disagreed, or disagreed. The purpose of the questionnaire was to assess the 200 participants' impressions of our remote simulation-based training protocol. We also focused 201 on educational equivalence of this remote training session compared to conventional on-site 202 training seminars. 203 204

First, we confirmed that the values of performance rating scores were normally distributed. 206

Data were listed as mean ± standard deviation. Paired t test was used to compare the scores 207 between the initial and last session. A P-value of <0.05 was considered statistically 208 significant. All statistical analyses were performed with EZR (Saitama Medical Center, Jichi 209

Medical University, Saitama, Japan), 10 which is a graphical user interface for R (The R 210 Average time of the prerecorded practice video was 13.9 ± 4.3 minutes per one anastomosis. 230

The key instruction was entrusted to each faculty, thus the manner of key instruction 231 varied. More than half the faculties presented key instructions orally (14/24, 58%), while 4 232 faculties (17%) gave slide presentations, and 6 faculties (25%) performed demonstrations of 233 anastomosis. 234

During the real-time demonstration by trainees, nearly all trainees (68/70, 97%) 235 successfully completed their anastomoses and received formative feedback from their faculty. thus the faculty could not give detailed feedback. One trainee (1%) could not complete 238 anastomoses due to a technical error. 239 240 Trainees' improvement on performance rating scores 241

The performance rating score comparison between the initial and last session is summarized 242

in Table 3 and Table 2 . All 252 (53/53, 100%) participants agreed that this remote training session was effective in improving 253 surgical skill. Additionally, the vast majority (45/53, 85%) of participants including trainees 254 (26/33, 79%) and faculties (19/20, 95%) reported that this remote training session was 255 equivalent to conventional on-site training seminars. Several participants noted that this 256 remote session was superior to conventional on-site seminars in that they could obtain more 257 individual and detailed feedback using a small-group teaching method. Performing 258 anastomoses with YOUCAN and Anasthon A-1 Kit was regarded as realistic enough for the 259 majority of trainees (23/33, 70%) and faculties (16/20, 80%), although the rest of participants 260 mentioned that it felt somewhat difficult and uncomfortable anastomosing YOUCAN inside an Anasthon A-1 Kit. Several faculties (10/20, 50%) argued that components of the 262 performance rating scores were not appropriate; they mentioned that anastomosing time 263

should be excluded because trainees should put a higher priority on quality, not time. anastomosis on the Zoom screen was much clearer and easier to observe than the actual 285 anastomosis site, which they had seen in the conventional on-site seminars. Therefore, Zoom 286 was considered an ideal distance education tool even for surgical training sessions. Thirdly, 287 the small-group (three trainees, one faculty, and one host) teaching system was suitable for 288 these remote sessions. This setting enabled faculty to observe each trainee's anastomosis carefully one by one, and give detailed formative feedback within the allotted time. To 290 maximize the skill acquisition within the limited time frame, we required trainees to perform 291 free practice before the session. This two-step skill training was largely accepted as a 292 beneficial method in the questionnaire survey (Table 2) . Lastly, the host played an important 293 and necessary role for smooth progress of remote sessions. The host had to manipulate the 294 Zoom application to guide the session properly, and assist active discussion between the 295 participants over the whole course. Accordingly, the hosts were elected from members of 296 JSCVS U-40, and were well trained during several rehearsals. As a result, we could achieve 297 the highly esteemed remote training sessions with 100% approval of the host's appropriate 298 operation in the faculties' questionnaire survey throughout the entire series of the sessions. 299

Educational experience with the training model may not be associated with 300 improved technical skills if the exposure is not repeated. 2, 16 The current result also supports 301 this theory: 13 trainees who repeatedly participated in the remote training sessions exhibited 302 performance improvement in their final session. Statistically significant performance 303 improvement was observed in the components of 'anastomosing skill of far/near side portion' 304 and 'external/internal appearance of the completed anastomoses', while most other 305 components of the performance rating scores also showed a nonsignificant trend toward 306 higher scores in the last session (Table 3 and Figure 4 ). The external/internal appearance of 307 the anastomoses, which exhibited most remarkable improvement, are considered to be the 308 most important evaluation points as they are directly linked to graft patency. These 309 components are tangible evaluation points reflecting comprehensive anastomosing skill; thus, 310 achievement of improvement can be observed more directly relative to the other technical 311 components. However, the current result is insufficient to determine whether our remote 312 sessions offer substantial technical improvement, because the available data regarding 313 performance rating was limited to only 13 (36%) trainees who participated repeatedly. As the preliminary remote training sessions was limited during the extraordinary circumstances 316 presented by the COVID-19 pandemic, we welcomed single participation and did not dare 317 organize the time-consuming curriculum to require multiple participation. A single 2-hour 318 remote training itself may be insufficient to produce significant performance improvement 319 for every participant, thus we did not conduct performance comparison between the baseline 320 and the end of each session. We rather aimed to notify trainees of their technical weaknesses 321 and ways to improve them within a single participation providing intensive faculty 322 supervision and individual performance assessment. We believed that these instructions 323 would encourage trainees to sharpen their skill through further constant daily practice by 324 themselves, after the session. As a result, there were 13 motivated trainees who participated 325 repeatedly with improved performance compared to their initial participation. This result 326 indicates that our remote session could successfully inspire some participants to achieve 327 performance improvement. of real patient care. 14, 19 Further exploitation of real tissue simulators, which are safely 350 available in the current virtual platform will be required. Additionally, there still remains a 351 challenge regarding administrative efficiency. Because online chat is suitable for small-group 352 bidirectional discussion, our preliminary remote training adopted individualized instruction in 353 a 3 to 1 trainee to faculty ratio, spending 2 hours per session for 24 sessions. This small-group 354 intensive method may be one of the reasons why the current remote training was highly 355 applauded by participants, whereas a much greater deal of labor was needed to administrate the 356 whole course compared to the past on-site training seminars which could involve far more 357 trainees at once. Future work should therefore aim to establish more efficient administration of 358 remote training programs. 359 360

Among the study limitations is dispersion of postgraduation duration in this study population 362 ranging 0-14 years. Also, participation frequency varied between individuals. In the current 363 series of remote training sessions, the above conditions were dependent on spontaneous useful data regarding performance evaluation, a larger uniform cohort needs to experience the 366 same curricula. 367

Another limitation is lack of performance rating consistency and equality. Although 368 the 5-point global rating scale adapted from OSATS is a widely used fundamental tool for 369 performance assessment, the rated scores eventually depended on each faculty's subjective 370 judgment, thus were not completely consistent. In addition, the current remote sessions 371 Additionally, trainees who participated repeatedly in our sessions showed more satisfactory 385 performance than their initial participation, indicating that our remote training could 386 successfully inspire a part of the participants to achieve significant performance improvement. 

Deliberate Practice in Simulation-Based Surgical Skills 2