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Original Investigation
March 1, 2017

Performance of Vascular Exposure and Fasciotomy Among Surgical Residents Before and After Training Compared With Experts

Author Affiliations
  • 1Shock Trauma Anesthesiology Research Center, University of Maryland School of Medicine, Baltimore
  • 2Department of Anesthesiology, University of Maryland School of Medicine, Baltimore
  • 3Department of Basic Medical Sciences, University of Arizona College of Medicine, Phoenix
  • 4Department of Anatomy and Neurosciences, University of Maryland School of Medicine, Baltimore
  • 5Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
  • 6Henry M. Jackson Foundation, Bethesda, Maryland
  • 7Joint Trauma System, Defense Center of Excellence for Trauma, US Army Institute of Surgical Research, San Antonio, Texas
  • 8Department of Surgery, University of Maryland School of Medicine, Baltimore
  • 9Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland
JAMA Surg. Published online March 1, 2017. doi:10.1001/jamasurg.2017.0092
Key Points

Question  Does Advanced Surgical Skills Exposure for Trauma training improve resident performance compared with expert traumatologists?

Findings  In a longitudinal cohort study that used the Trauma Readiness Index, most residents had significantly improved correct procedural steps and anatomy skills and decreased errors after a 1-day Advanced Surgical Skills Exposure for Trauma course, and core competency skills were retained for up to 18 months. Experts performed significantly better than residents.

Meaning  Advanced Surgical Skills Exposure for Trauma provides training in trauma core competencies, and the Trauma Readiness Index can identify those residents who require remedial interventions in trauma technical skills.


Importance  Surgical patient outcomes are related to surgeon skills.

Objective  To measure resident surgeon technical and nontechnical skills for trauma core competencies before and after training and up to 18 months later and to compare resident performance with the performance of expert traumatologists.

Design, Setting, and Participants  This longitudinal study performed from May 1, 2013, through February 29, 2016, at Maryland State Anatomy Board cadaver laboratories included 40 surgical residents and 10 expert traumatologists.

Interventions  Performance was measured during extremity vascular exposures and lower extremity fasciotomy in fresh cadavers before and after taking the Advanced Surgical Skills for Exposure in Trauma (ASSET) course.

Main Outcomes and Measures  The primary outcome variable was individual procedure score (IPS), with secondary outcomes of IPSs on 5 components of technical and nontechnical skills, Global Rating Scale scores, errors, and time to complete the procedure. Two trained evaluators located in the same laboratory evaluated performance with a standardized script and mobile touch-screen data collection.

Results  Thirty-eight (95%) of 40 surgical residents (mean [SD] age, 31 [2.9] years) who were evaluated before and within 4 weeks of ASSET training completed follow-up evaluations 12 to 18 months later (mean [SD], 14 [2.7] months). The experts (mean [SD] age, 52 [10.0] years) were significantly older and had a longer (mean [SD], 46 [16.3] months) interval since taking the ASSET course (both P < .001). Overall resident cohort performance improved with increased anatomy knowledge, correct procedural steps, and decreased errors from 60% to 19% after the ASSET course regardless of clinical year of training (P < .001). For 21 of 40 residents (52%), correct vascular procedural steps plotted against anatomy knowledge (the 2 IPS components most improved with training) indicates the resident’s performance was within 1 nearest-neighbor classifier of experts after ASSET training. Five residents had no improvement with training. The Trauma Readiness Index for experts (mean [SD], 74 [4]) was significantly different compared with the trained residents (mean [SD], 48 [7] before training vs 63 [7] after training [P = .004] and vs 64 [6] 14 months later [P = .002]). Critical errors that might lead to patient death were identified by pretraining IPS decile of less than 0.5. At follow-up, frequency of resident critical errors was no different from experts. The IPSs ranged from 31.6% to 76.9% among residents for core trauma competency procedures. Modeling revealed that interval experience, rather than time since training, affected skill retention up to 18 months later. Only 4 experts and 16 residents (40%) adequately decompressed and confirmed entry into all 4 lower extremity compartments,

Conclusions and Relevance  This study found that ASSET training improved resident procedural skills for up to 18 months. Performance was highly variable. Interval experience after training affected performance. Pretraining skill identified competency of residents vs experts. Extremity vascular and fasciotomy performance evaluations suggest the need for specific anatomical training interventions in residents with IPS deciles less than 0.5.