Monitoring Performance and Progression in the Operating Theatre

Abstract

Although previous chapters indicated the potential and benefits of training arthroscopic skills in simulated environments, training needs to be continued in the operating room to achieve the necessary proficiency. Based on the theory on learning strategies in Chap. 4, it is posed that if residents indeed acquire the basic skills before they enter the operating room, the focus in the operating room can be on more complex tasks. This requires the formulation of guidelines that determine the level that qualifies proficiency. For the actual cases in the operating room, this is a difficult task as the level of complexity of the procedure plays an important role, and proficiency is not necessarily defined as the summation of several part-task skills, but rather requires a holistic approach.

Appendices

Appendix 13.A Orthopaedic Competence Assessment Project

Skill	Score 1	Score 2	Score 3	Score 4	Score 5
Follows protocol	Unsatisfactory		Adequate. Occasional need for guidance and help		Excellent adherence to agreed protocol. No prompts. No mistakes
Handles tissue well	Careless. Potential to cause damage		Adequate. No tissue damage. Occasional need for increased care		Excellent tissue handling. Precise and delicate
Appropriate and safe use of instruments	Dangerous. Risk to patient and assistant. Potential for damage to equipment		Adequate use of instruments and scope. Occasional guidance to ensure instruments remain within field of vision		Excellent use of instruments. Good control of arthroscope. Instruments constantly within field of vision
Appropriate pace with economy of movement	Erratic pace and movements. Overly rushing or inappropriately slow		Adequate economy of movement. Majority of movements controlled and careful. Occasional erratic movement		Excellent fluidity and economy of movement. Procedure performed at appropriate pace without erratic movements
Act calmly and effectively with untoward events	Unable to deal with adverse events. Panic and inability to respond		Remains calm. Remains safe. Takes advice from supervisor. Unable to cope independently		Excellent ability to cope with adverse events. Remains calm. Deals with complication independently
Appropriate use of assistant	Fails to involve assistant appropriately. Resultant poor positioning. Poor rapport		Asks for appropriate joint position at appropriate times. Unable to suggest alternative positions to improve view/access		Excellent use of assistant. Good rapport. Able to constantly modify input of assistant to best advantage throughout procedure
Communicates with scrubs nurse	Inappropriate communication resulting in confusion or operative delay		Appropriate communication with scrub nurse. Occasional need for clarification from supervisor		Excellent rapport with scrub nurse. Clear and effective communication, maximising procedural efficiency
Clearly identifies common abnormalities	Unable to identify common abnormalities. Confusion over basic anatomy		Adequate identification of common pathology. Occasional mistake. Unsure of precise classifications		Excellent knowledge of pathology of common abnormalities. Clear understanding of classification of injuries
Protecting the articular surface	Inability to protect articular surface appropriately. Potential to cause damage		Awareness of need to protect articular surface. Adequate care taken. Occasional prompt from supervisor required		Excellent awareness of articular surfaces. High degree of care maintained throughout the procedure

Appendix 13.B Basic Arthroscopic Knee Skill Scoring System

Skill	Score 1	Score 2	Score 3	Score 4	Score 5
Dissection	Appeared excessively hesitant, caused trauma to tissues, did not dissect into correct anatomical plan		Controlled and safe dissection into correct anatomical plane, caused minimal trauma to tissues		Superior and atraumatic dissection into the correct anatomical plane
Instrument handling	Repeatedly makes tentative or awkward movements with instruments		Competent use of instruments, although occasionally appeared stuff or awkward		Fluid moves with instruments and no awkwardness
Depth perception	Constantly overshoots target, slow to correct		Some overshooting or missing of target		Accurately directs instruments in the correct plane to target
Bimanual dexterity	Noticeably awkward with non-dominant hand, poor coordination between hands		Uses both hands but does not maximise interaction between hands		Expertly uses both hands in complementary manner to provide optimum performance
Flow of operation and forward planning	Frequently stopped operating or needed to discuss next move		Demonstrated ability for forward planning with steady progression of operative procedure		Obviously planned course of operation with effortless flow from one move to the next
Knowledge of instruments	Frequently asked for the wrong instrument or used inappropriate instrument		Knew the names of most instruments and used appropriate instrument for the task		Obviously familiar with the instruments required and their names
Efficiency	Many unnecessary, inefficient movements. Constantly changing focus or persisting without progress		Slow, but planned movements are reasonably organised with few unnecessary or repetitive movements		Confident, clear economy of movement and maximum efficiency
Knowledge of specific procedure	Deficient knowledge, needed specific instruction at most operative steps		Knew all important aspects of the operation		Demonstrated familiarity with all aspects of the operation
Autonomy	Unable to complete entire task, even with verbal guidance		Able to complete task safely with moderate guidance		Able to complete task independently without prompting
Quality of final product	Very poor		Competent		Clearly superior

Appendix 13.C Arthroscopic Skills Assessment

Start time	Stop time	Total time
Landmark	To be visualised	Score
Suprapatellar pouch	View all areas of pouch	(3)
Patella	View medial facet	(3)
	View lateral facets	(3)
Trochlea	View trochlear surface	(4)
Medical recess	View medial gutter/assess meniscal synovial junction	(4)
Lateral recess	View lateral gutter/assess meniscal junction/popliteus	(4)
Medial compartment	Assess condyle for chondral lesions	(5)
	Meniscus/view anterior, middle, posterior	(5)
	Probe superior and inferior surface	(10)
Intercondylar notch	View and inspect ACL	(5)
	View and inspect PCL	(5)
Lateral compartment	Assess condyle for chondral lesions	(5)
	Meniscus/view anterior, middle, posterior	(5)
	Probe superior and inferior surface	(10)
	View popliteus tendon	(4)

	Missed items	Scope score
Time	Time penalty	Total time score
		Total score

Appendix 13.D Objective Assessment of Arthroscopic Skills

Skill	Novice	Advanced beginner	Competent	Proficient	Expert
Examining/manipulating joint	Did not examine joint or position to give improved visualisation during procedure	Examined joint without diagnostic abilities and lacked ability to facilitate view by positioning	Positioned knee appropriately after some difficulty with visualisation	Used common positioning to facilitate view during arthroscopy	Used accepted and novel positioning to perform the arthroscopy effortlessly
Triangulating instruments	Could not insert instruments into ports and maintain them in view. Unable to locate instrument tips without difficulty	Unable to maintain instrument in field of view consistently	Found instruments with delay. Field of view wandered from operative site but returned	Found instruments quickly and began work. Occasionally delayed in orienting camera to afford better visualisation	Immediately located instruments and began work without delay. Kept instrument in field of view at all times
Controlling fluid flow and joint distension	Under-/overdistended joint consistently due to inappropriate matching of suction and flow.	Achieved proper distension after delays. Some extravasation into tissue due to overdistension	Distended joint adequately after initial loss of pressure during suction	Joint distended appropriately through control of flow and suction	Minimal fluid extravasated with constantly maintained field of view
Maintaining field of view	Often disoriented. Was unable to adjust scope to improve visualisation	Maintained field of view part of the time	Maintained and adjusted arthroscope to provide maximal view with some difficulty	Maintained field of view in same portal	Changed portals quickly to improve visualisation
Controlling instruments	Was unable to perform tasks with provided instruments. Caused cartilage damage	Repeatedly made tentative or awkward moves with instruments	Competently used instruments although occasionally appeared stiff or awkward	Used instruments appropriately and efficiently	Made fluid moves with instruments and used some instruments in novel ways to increase efficiency
Economising time and planning forward	Was unable to complete any portion of the procedure	Was able to complete components of the procedure, but needed to discuss next move	Completed all components of the operation with some unnecessary moves	Was efficient, but continued discovering new time saving motions	Showed economy of movement and maximum efficiency
Overall	Possessed rudimentary arthroscopic skills with only basic anatomical and mechanical understanding	Knew basic steps of procedure and performed some independently	Performed the procedure independently	Performed procedure with changes to improve efficiency	Performed the procedure with minimal chance to improve efficiency
Complexity	No difficulties	Slightly difficult	Moderately difficult	Considerable difficulty	Critical

Appendix 13.E Arthroscopic Surgical Skill Evaluation Tool

Skill	Score 1	Score 2	Score 3	Score 4	Score 5
Safety	Significant damage to articular cartilage or soft tissue		Insignificant damage to articular cartilage or soft tissue		No damage to articular cartilage or soft tissue
Field of view	Narrow field of view, inadequate arthroscope or light source positioning		Moderate field of view, adequate arthroscope and light source positioning		Expansive field of view, optimal arthroscope and light source positioning
Camera dexterity	Awkward or graceless movements, fails to keep camera centred and correctly oriented		Appropriate use of camera, occasionally needs to reposition		Graceful and dexterous throughout procedure with camera always centred and correctly
Instrument dexterity	Overly tentative or awkward with instruments, unable to consistently direct instruments to targets		Careful, controlled use of instruments, occasionally misses targets		Confident and accurate use of all instruments
Bimanual dexterity	Unable to use both hands or no coordination between hands		Uses both hands but occasionally fails to coordinate movement of camera and instruments		Uses both hands to coordinate camera and instrument positioning for optimal performance
Flow of procedure	Frequently stops operating or persists without progress, multiple unsuccessful attempts prior to completing tasks		Steady progression of operative procedure with few unsuccessful attempts prior to completing tasks		Obviously planned course of procedure, fluid transition from one task to the next with no unsuccessful attempts
Quality of procedure	Inadequate or incomplete final product		Adequate final product with only minor flaws that do not require correction		Optimal final product with no flaws
Autonomy	Unable to complete procedure even with intervention(s)		Able to complete procedure but required intervention(s)		Able to complete procedure without intervention
Complexity	No difficulty		Moderate difficulty (mild inflammation or scarring)		Extreme difficulty (severe inflammation or scarring, abnormal anatomy)