Tie Knots to NOTSS for safe Surgery

We are interested in developing a training program aiming at teaching the essential surgical skills for healthcare providers in rural areas to improve access to safe and affordable surgery. Based on the Lancet commission on Global Surgery, Bellwether procedures (open fracture management, cesarean section, and laparotomy) are critical skills required to improve access to safe Surgery globally. After the release of the Lancet commission on Global Surgery report, a number of countries have developed National Surgical Obstetric and Anesthesia Plans. However there is no clear guidance and support on how to teach these essential skills. Moreover it has been revealed that more than 50% of surgical errors are due to lack of non-technical skills like effective communication and teamwork. This project intends to develop a training program for general practitioners from Low and Middle-Income countries to perform Bellwether procedures by integrating technical and non-technical skills education.

This program will use 3D printing technology to build simulation models. 3D printing files will be built from CT scans of real patients. We will 3 D print models that will be used to learn the technical skills. We will also create rubrics for self-assessment for the users to assess and track their competencies. 

The training program will have three phases: simulation model building, Didactic (anatomy and description of how to perform the procedures), procedural skills learning and self-assessment. In addition to procedural skills training, we will include non-technical skills for surgeons (situation awareness, decision making, leadership, communication and teamwork) necessary for safe surgical care. Video-recorded lectures, didactics, readings and other study materials will be developed and uploaded on a website and made publicly available.  Users will be requested to provide their names, E-mail, and working area so that we track usage, and request them feedback on how we can best support them.

This project will focus on the following skills:

Laparotomy: Opening and closing the abdomen, controlling intra-abdominal bleeding (damage control surgery like perihepatic packing and splenectomy).

Open fracture management: wound debridement and wash out, limb immobilization (by external fixation or back slab).

Cesarean section: we will focus on uterus suture because poor uterine repair may cause post partum-hemorrhage or intra-abdominal infections, or fistula...)

Videos: video records of live procedures to illustrate the real life procedures. During the video, the instructor will talk through them to explain essential steps of performing the procedures. The videos will also be used to teach pattern recognition intra-operative decision making.

Non-technical skills: for each procedure, we will describe the non-technical skills necessary to safely perform that procedure. 

During practice of technical skills (if more than one person is learning the skills; their peer will use the NOTSS rating tool to discuss/ debrief the non-technical skills after performing the procedures).

Self-assessment tools: for each procedures, we will define competencies required to perform the procedures and produce self assessment tools (rubrics) to assess the progress (assessment for improvement). Rubrics will allow learners to reflect on their performance and learn what they can do to improve.

The primary beneficiaries of this technology are surgical care providers, especially general practitioners/ medical officers working in district hospitals in low and middle income countries, who don't have access to training materials. These tools can also be used by specialist surgeons and Obstetricians while teaching medical students, or provide continuous medical education to general practitioners from rural areas. Over the last two years we implemented a project on teaching technical and non-technical skills in Rwandan district hospitals. We found out that general practitioners have basic surgical skills and they need further training to perform the Bellwether procedures. Due to workload, and limited funds for travel, our beneficiaries need training programs that they can take without from their hospitals. People who participated in our program appreciated the integration of technical and non-technical skills. Limitation of our previous project is that we used patients in teaching technical skills, and it was not easy to find patients who have the diseases that we were interested in teaching. Additionally, for patient safety, the instructors performed the most critical steps of the procedure, which compromised effective learning.

Team lead:  Dr Barnabas Alayande, general surgeon, global surgery fellow at the University of Global Health equity (UGHE) in Rwanda. He will lead the team and oversee the development, implementation, and reporting of the project. He will oversee model development from UGHE simulation center.

Educators: 

Dr Egide Abahuje:is a general surgeon from Rwanda. He has a masters of science in Health Professions Education. He completed a fellowship in simulation medical education from USA. He is also doing a PhD in Health professions Education at MGH Institute of Health Professions. He will manage the pedagogical objectives of the training modules

Prof Steve Yule

Dr Roger D Dias 

Clinicians:

1. Dr Lambert Dusingizimana Rutayisire: He is an orthopedic surgeon from Rwanda.  

2. Dr Jean Damascene Rukundo: He an Obstetric and Gynecologist from Rwanda, lecturer at the University of Rwanda. 

3. Dr Miguel Gasakure

4. Dr Robert Riviello:  expert in global surgery, trauma and critical care.

6. Dr Becky Sandford: Vascular surgeon from UK

Technical expert: Christopher Williams

Medical illustrator: Kuukua Wilson, Ghana

Project manager: Wendy Williams, USA