SIMULATION TRAINING TO IMPROVE CLINICAL DECISION-MAKING BY SURGICAL RESIDENTS

Purpose:   Training to improve clinical decision-making skils, improve patient care and reduce potential medical errors often focuses on communication between health care providers.  Physician-to-physician handoffs, especially those requiring rapid decisions under time constraints, are a critical point of incorrect, incomplete or misunderstood communication, especially for surgical residents who’s educational objective is to acquire this skill.  Our objective was to evaluate the effectiveness of simulation training to improve clinical information transfer between surgical residents and attending physicians in order to establish a baseline of expected skill development and validate a standardized process for skill acquisition.

Method:   This decision-making skill improvement process focused on surgical residents in a University–based General Surgery Residency Program.  All general surgery residents (PGY1 – PGY5) were included based on the requirement of a handoff policy developed by the program consistent with ACGME standards for knowledge and skill acquisition.  The Operating Room Communications Assessment tool (ORCA) was modified for use with the SBAR communication tool used by the program and pilot tested, as were standardized clinical scenarios.  All students were evaluated in a simulation lab while receiving (and evaluating) an outside surgical transfer call request and subsequently presenting a clinical summary by phone to an attending physician.  All calls were audio taped and evaluated by trained staff using a Likert 4 point scoring system.  A training program to review and practice SBAR occurred following the initial pre-intervention testing after which all students completed identical post-intervention testing.

Result:   Forty surgical residents participated in the study.  Twenty-six were junior resident (PGY1 and PGY2) and fourteen were senior residents (PGY3, PGY4, PGY5). All residents demonstrated significant improvement on mean scores on transfer of clinical information (to the attending) at a p<.001. They did not demonstrate improvement on mean scores, p=>.05, for receiving clinical information (from the transfer call). Junior residents demonstrated significant increases in mean receiver and transmitter scores from pre to post testing at p=.026 and p=.008 respectively. Senior residents did not demonstrate statistical significance at p=<.05 on either measure. Pearson correlations for inter-rater reliability between initial and repeat receiving and transmitting information were r=.863 and r=.963 respectively.

Conclusion:   Simulation training of a critical clinical skill contributing to rapid decision-making under short-term time constraints can be effective in residency education, especially at the junior level.