Professional Documents
Culture Documents
DOI 10.1007/s00464-014-3941-8
Received: 10 June 2014 / Accepted: 7 October 2014 / Published online: 15 November 2014
Springer Science+Business Media New York 2014
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simple implementation of ERP (absence of NG tube, epi- colonoscopy, results were available (‘‘there are some
dural analgesia in case of open surgery, early use of oral diverticula in the sigmoid colon’’), and the trainee was
analgesia, perioperative nutrition, early mobilization) [22] asked to discuss the benefits and risks of surgery. A new
and decision making for more complex cases. Their screen opened showing ‘‘the patient wants to be operated’’
objectives were to identify the patient’s post-operative and the trainee could plan for ERP, according to the
progression and initiate an appropriate management plan following items: type of operation (laparoscopic sigmoid
according to ERP, similar to how a surgeon should perform colectomy with colorectal anastomosis), information
in the surgical ward. concerning the operation and its risks (conversion into
open surgery, stoma, anastomotic leak), bowel preparation
(‘‘the consultant does not agree with your decision’’), pre-
operative fasting (6 h solid, 2 h clear fluids, and carbo-
Results hydrate loading), no anesthetic premedication, and dis-
charge plan (home at Day 4, telephone call after 24 h and
Pre-operative training scenarios clinical review at Day 8 and 30).
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VP6
VP7
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the patient and proceed to laparoscopy first, with either consensus stated that continuing education of new team
lavage, covering loop ileostomy and drainage, or conver- members was one of the three most important leads to
sion into open surgery, Hartmann’s procedure, lavage and sustain success in ERP, along with regular staff update
abdominal drainage given the local conditions. sessions and positive feedback to team [6].
Pearsall et al. interviewed 55 surgeons, anesthetists and
nurses: they found that surgeons cited themselves and resi-
Discussion dents as barriers to ERP. With regard to residents, some
surgeons were concerned that they might not follow ERP
This study, following a pilot study based on a pathway because of lack of awareness [1]. Nadler et al. interrogated 77
approach for acute appendicitis [14], designed four pre- residents in surgery on ERP: they stated that fluid diet would
operative and five post-operative VP presenting with var- be ordered on Day 0 and regular diet on Day 1 by 68 % and
ious colorectal diseases. The aim was to manage VP 49 %, respectively, after laparoscopic colectomy, but only by
according to ERP guidelines [19, 20], and scenarios ranged 50 % and 26 % following open colectomy; in patients with
from trivial to more complex cases, from uneventful to an epidural, approximately 50 % of residents stated that they
complicated courses. Cases involved knowledge in colo- would wait until it was removed to discontinue urinary
rectal diseases and ERP, as well as decision-making. They catheter. Overall, they had a reasonable approach to the
also took into account ‘‘real life’’ practice with both lapa- management of patients who underwent laparoscopic colec-
roscopic and open cases, as well as conversions into open tomy, but there were gaps in their management, especially
surgery. Such patients could be included in a whole sim- following open colectomy and laparoscopic anterior resection
ulated pathway care training, involving technical and non- [2]. Education and training are therefore needed for residents
technical skills: this pathway care training would enable in ERP. Moreover, though designed for residents in first
residents to follow virtual colorectal patients from initial intent, our VP may also be useful for practicing surgeons to
clinical review to discharge. increase implementation to ERP.
The key concepts of ERP in colorectal surgery include Experiential lectures are currently used in the educational
patient education and preparation, preservation of gut system for non-technical skills training, mostly without
function, minimization of organ dysfunction, minimization interaction or any notion of problem-based learning. Several
of pain and discomfort, and promotion of patient autonomy fields of research have been developed to design interactive
[23]. Several meta-analyses, through 13 randomized con- training models for non-technical skills. These models have
trolled trials, found that ERP decreased length of hospital been developed for intraoperative as well as pre- and post-
stay and global morbidity, despite no differences were operative care. Teamwork training has been designed in the
found in mortality and surgical morbidity. [24–26] A recent simulated OR, mainly for crisis scenarios [30, 31]. As for pre-
series of 541 colorectal procedures, performed according to and post-operative care, training models have already been
ERP, showed that compliance with oral intake and fluid designed in the simulated ward [7–9] and in the virtual world
management in the first 48 h significantly decreased post- [10–14]. Both have demonstrated fidelity, content validity,
operative morbidity [27]. Moreover, Aarts et al. found that and educational value [11, 15]. The simulated ward has the
pre-operative counseling, laparoscopy, reintroduction of advantage to be highly immersive, using actors that can per-
clear fluids at Day 0, and early discontinuation of urinary fectly mimic patients’ examination (such as abdominal ten-
catheter were significantly associated with length of derness, guarding, or vomiting) within an environment
stay \5 days in multivariate analysis [28]. In the LAFA- looking very much like a real surgical ward, including drug
trial, Vlug et al. demonstrated that laparoscopy associated charts and patient notes [7, 8]. However, simulated ward is
with ERP decreased total hospital stay [29]. Despite these expensive and presents both access issues and time con-
benefits, compliance to ERP remains an issue in everyday straints. In contrast, VP, designed in the virtual world of
practice. Second LifeTM, are free for end-users and easily accessible for
Indeed, compliance to colorectal ERP would only be everyone from a personal computer, hence easily dissemi-
60–70 % [3, 4], and tends to decrease with time, even in nated to large groups [32]. VP are therefore an attractive tool
reference centers [5]. An audit, comparing consecutive for training in clinical skills, for a growing number of aca-
colorectal patients with patients included in a trial, found demic institutions. [33–35].
that ERP observance was significantly lower outside the In the present study, VP were designed and developed
trial (for example, 61 vs. 96 %, P \ 0.001, for carbohy- using a framework published by our group [10], according
drate loading) [4]. This led Cakir et al. to write that to the guidelines of Posel et al. [33–35]. Previous design
‘‘embedding ERP into an organization and repetitive edu- methods have been described for VP. They include the
cation are vital to sustain its beneficial effects on length of linear string and the branching design method [37]. While
stay and outcome’’ [5]. Likewise, a recent Delphi the branching method provides higher fidelity [18] it is
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more complex in terms of design. We therefore chose the Disclosures Rajesh Aggarwal is funded by a Clinical Scientist
linear string method so that if the trainee chose the correct Award from the National Institute of Health Research, U.K. (Award
Grant Number NIHR/CS/009/001), and a consultant for Applied
clinical decision then the case would end accordingly. The Medical. Laura Beyer-Berjot, Vishal Patel, Paul Ziprin, Dave Taylor,
chosen scenarios corresponded to standard ERP pathway. Stéphane Berdah, and Ara Darzi have no conflicts of interest or
However, ERP are continuously evolving [22], and the financial ties to disclose.
designed VP could be found somehow rigid, in terms of
‘‘real-life’’ situations. The present project was proof of
practice: in the future, modules could be modified References
according to ERP evolution and/or local practice, and
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