Evaluation of a daily activity diary for chronic pain patients

The present study examined the reliability and validity of a daily activity diary for chronic pain patients. The diary assesses various postures and activities including time spent lying, sitting, or standing/walking, the use of pain relief devices, time spent in pain relief activities, and the use of analgesic medications. The methodology compared patient self-report on the daily activity diary to spouse observations of the same activities. In addition, patient self-report of uptime/downtime was compared to the objective assessment of uptime/downtime by an automated electromechanical device. Reliability coefficients for the daily activity diary categories were all positive and statistically reliable as were correlations between patient and spouse ratings on lying down time, time spent standing/walking, and pain intensity. Also, patient self-report of medication use correlated significantly with spouse pill count. Finally, the correlation between patient report of lying down time and downtime as measured by the electromechanical monitor was also positive and highly significant. These results indicate that the daily activity diary is a reliable and valid instrument for the assessment of daily activity patterns of chronic pain patients in their natural environment. These results are discussed in relation to other research and the use of daily diaries for assessment and treatment outcome research with this population.     

Effect of live music therapy for patients undergoing magnetic resonance imaging

The purpose of the current study was to identify the effects of live music therapy interventions compared with preferred recorded music for patients undergoing MRI scans. To date, there has not been a published study involving the use of live music therapy during MRI scans. The current study investigated the differences between teenage through adult patients receiving live music therapy intervention during outpatient MRI scans versus the standard protocol of care listening to recorded music (N = 88). Subjects ranged in age from 15 to 93 years old. Results indicated subjects who received the live music therapy protocol reported significantly better perception of the MRI procedure (p < 0.05). Additionally, subjects receiving the live music therapy protocol had fewer scans repeated due to movement. Of the repeated images, 26% occurred in the live music group and 73% occurred in the recorded music group. Subjects receiving live music therapy also requested less breaks from the scan. Two percent of the live music subjects requested a break and 17.6% of the control patients requested breaks. When comparing the same type of scan between groups, subjects receiving the live music protocol required less time to complete the scans. For lumbar scans without contrast (N = 14, n = 7, n = 7), live music subjects spent an average of 4.63 less min per scan for a total of 32 less min for 7 subjects. For brain scans (N = 8, n = 4, n = 4), live music subjects spent an average of 5.8 less min per scan for a total of 23 less min for 4 subjects. Results of the current study supports the use of live music therapy intervention for teenage and adult patients undergoing MRI scans to reduce patient anxiety and improve patient perception of the scan experience. Additionally, live music therapy has the potential to shorten the length of time required for patients to complete MRI scans due to decreased patient movements and fewer breaks requested during the scans. The cost savings impact of reduced procedure time can positively impact the facility productivity by allowing more scans to be scheduled daily.     

Use of flexible fiberoptic endoscopy for determination of endotracheal tube position in the pediatric patient

Flexible fiberoptic endoscopy (FFE) was utilized in a series of 24 critically ill pediatric patients to determine the position of the endotracheal tube (ETT) tip relative to the carina. Training on a model system revealed no significant differences in predicting ETT-to-carina distance (ETT-C) with respect to operator, ETT size, or absolute ETT-C as measured directly. No significant differences in ETT-C could be determined between traditional bedside chest x-ray (CXR) or FFE when FFE was performed on intubated pediatric ICU patients. A correlation coefficient comparing the two methods was 0.767. Neither ETT size nor FFE operator affected this correlation. Although used as the gold standard, CXR failed to demonstrate the carina clearly in 15 patients. FFE delineated the carina clearly in 22 patients. Ability to visualize ETT placement within the trachea was essentially identical for FFE (22/24) compared to CXR (23/24). However, the time required to obtain this information was significantly different: 30.6 min (range 13 to 57) for CXR; 40 sec (range 16 to 94) for FFE. No clinically significant changes in patient pulse oximetry, heart rate, or physical exam were observed during FFE. Only copious secretions impaired the utility of FFE. We concluded that FFE is a safe, fast, easily learned method to determine relative ETT position or precise ETT-C in the mechanically ventilated pediatric patient.     

Factors associated with the time nurses spend at the bedsides of seriously ill patients with poor prognoses

BACKGROUND: Little is known about the time health professionals spend with inpatients that are close to the end of life. SUBJECTS AND METHODS: We asked day-shift nurses to use a standardized log sheet to record how much time they spent in various categories of activity for 146 seriously ill medical inpatients with poor prognoses at 2 teaching hospitals. RESULTS: The mean patient age was 68, and the mean APACHE-III physiology score 28; 59% were white, 56% were women, 41% had cancer or HIV, and 81% had do not resuscitate (DNR) orders. The mean amount of time nurses spent with patients per 12-hour day shift was 53 min. In bivariate analyses, sex, religion, diagnosis and insurance status were not associated with nursing bedside time. In an ANOVA model, patients with DNR orders received more time than those without DNR orders (56 vs. 39 min, P = 0.04), and white patients received more bedside time than nonwhites (57 vs. 46 min, P = 0.01), even after controlling for severity of illness and DNR status. Among the 47 mentally alert patients who could be interviewed, symptom severity, quality of care, and satisfaction ratings were not associated with nursing bedside time. CONCLUSIONS: In this population, nurses spent less time with nonwhite patients and more time with patients with DNR orders. That patients with DNR orders received more time may be reassuring. However, further investigation will be required to confirm these results, to understand why nonwhite patients appear to have received less bedside nursing time, and to investigate further the relationship between time, satisfaction, and quality of care.     

Critical care by emergency physicians in American and English hospitals.

The object of this study was to compare emergency physician critical care services in an American (A) and an English (E) Emergency Department (ED). A prospective case comparison trial was used. The study was carried out at two university affiliated community hospitals, one in the U.S.A and one in England. Subjects were consecutive patients triaged as requiring critical care services and subsequently admitted to the hospital ward (A, n = 17; E, n = 18) or the intensive/critical care unit ([ICU] A, n = 14; E, n = 24). The study time period was randomly selected 8-h shifts occurring over a 4-week period. All patients were treated by standard guidelines for critical care services at the study hospital emergency department. For all study patients mean length of stay was significantly longer for the American (233 min, 95% CI 201, 264) than the English ED (24 min, 95% CI 23, 25). American emergency physicians spent less total time providing physician services (19.2 min, 95% CI 16.8, 21.6) vs. (23 min, 95% CI 21.6, 24.4) than English emergency physicians. American emergency physicians spent less time with the patient than English emergency physicians: 12.4 min (95% CI 10.3, 14.5) vs. 17 min (95% CI 15.8, 18.2). American emergency physicians spent more time on the telephone 1.8 min (95% CI 1.4, 2.2) vs. 1.2 min (95% CI 1.1, 1.3), and in patient care discussions/order giving 1.8 min (95% CI 1.4, 2.2) vs. 1.1 min (95% CI .8, 1.4), There was no significant difference in time charting (3.2 min, 95% CI 2.8, 3.6 vs. 3.5 min, 95% CI 3.2, 3.8). Results did not vary significantly whether analysed subgroups or the whole study group. American emergency physicians provided 81% of their service during the first hour. There were delays at the American hospital until the physician saw the patient: 4.9 min (95% CI 2.5, 7.3) for patients admitted to the ICU/CVU (Cardiovascular Unit), and 9.2 min (95% CI 4.6, 13.8) for patients admitted to the ward. At the American hospital, ICU/CVU physicians provided additional physician services in the emergency department whether the patient was admitted to the ward (6.7 min, 95% CI 5.5, 7.9) or the ICU/CVU (12.1 min, 95% CI 8.8, 15.9). For patients admitted to the ICU/CVU 47% of the length of stay was spent waiting for a bed to become available after the decision to admit had been made. Emergency physicians at E provided critical care services almost continuously during a short stay in the ED. Emergency physicians at A provided services intermittently with most services during an initial period of stabilization. Further study is necessary to identify what factors contribute to these different approaches to critical care in the ED.     

The SADE system: an endoscopic database manager.

The development of the SADE database manager was commenced in 1985 since no commercially available systems were suited for the needs of a large endoscopy unit. Over a period of five years, this database was programmed, revised and enhanced through the joint efforts of gastroenterologists and programmers, the SADE system being implemented for daily use on 1 January 1989. The patient administration and medical record modules are fully implemented and functional, while the statistical module has only recently been finished. The present features of the system are described, and the limitations discussed. Instant report generation and direct access to previous medical data are the most immediate benefits of the system. The initial intention to have structured anamnestic data had to be modified to suit the need for flexibility and ease of free text input by the users.     

Resistance of pediatric and neonatal endotracheal tubes: influence of flow rate, size, and shape

OBJECTIVE: The aim of this study was to determine the resistances of endotracheal tubes (ETTs) commonly used in neonatal and pediatric intensive care units and the relationship of resistance to flow rate, size, and shape of ETT. SETTING: Laboratory-based measurements. EVALUATION: We examined straight tubes with inner diameters between 2.5 and 6 mm and shouldered (Cole) tubes with inner diameter/outer diameter between 2.5/4 and 3.5/5 mm. We assessed ETT resistance at standard and "appropriate for patient use" lengths at flow rates from 0 L/min to 30 L/min. We used calibrated rotameters to control the flow of gas and proximal static pressure measured by using either an industrial draft gauge or a differential pressure transducer. The ETT resistance was calculated by dividing the proximal ETT pressure by the measured flow and expressed as the mean of three measurements at each flow rate. MAIN RESULTS: Resistance increased as ETT diameter decreased; at flows of 5 L/min and 10 L/min, the resistances of the 6 mm inner diameter ETT were 3.1 H2O/L/sec and 4.6 cm H20/L/ sec, respectively, and the resistances of the 2.5 mm inner diameter ETT were 81.2 H2O/L/sec and 139.4 cm H20/L/sec, respectively. Shortening an ETT to a length appropriate for patient use (e.g., a 4.0 mm inner diameter, from 20.7 to 11.3 cm) reduced its resistance on average by 22%. The resistance of a Cole tube was approximately 50% lower than that of a straight tube with an inner diameter corresponding to the narrow part of the shouldered tube. CONCLUSIONS: Our results suggest that the use of a small-diameter, straight ETT will significantly increase the work of breathing.     

The effect of IM ketorolac tromethamine on bleeding time: a prospective, interventional, controlled study

Opiates, although effective analgesics, have significant adverse side effects. Ketorolac, the only parental nonsteroidal antiinflammatory drug available for use in the United States does not cause significant respiratory depression or hypotension, but it is a reversible inhibitor of platelet aggregation with a theoretical increased bleeding risk, which limits its use. The objective of this study was to determine the effect of a single intramuscular dose of 60 mg ketorolac on 4-hour bleeding times in healthy volunteers. This was a prospective, paired, unblinded, before-and-after interventional study performed in a suburban university-based EM residency training program. Subjects were 20 healthy volunteer EM residents. Standard Ivy bleeding times were measured before and 4 hours after intramuscular administration of 60 mg ketorolac. Before-and-after bleeding times were compared using a paired t-test. The study had 90% power to detect an effect size of 0.5. The subjects' mean age was 31.6 and 7 (35%) were females. Bleeding time was increased from a mean baseline time of 3 minutes 34 seconds (+/- 1 min 20 sec) to a mean 4-hour postinjection time of 5 minutes 20 seconds (+/- 3 min 8 sec). The mean prolongation of bleeding time was 1 minute 46 seconds (50% increase with 95% confidence interval, 25%-75%). There were no adverse events. A standard intramuscular dose of 60 mg ketorolac resulted in prolongation of the bleeding time in healthy volunteers. The clinical significance of this prolongation in patients is unclear.     

Endoscopic evaluation of peptic ulcer disease during ramadan fasting

The effects of fasting on peptic ulcer disease were evaluated in a prospective study, involving 23 fasting patients who underwent endoscopy before and after Ramadan. Eighteen patients took an H(2)-blocker (ranitidine, 150 mg twice daily) regularly at "Suhur" and "Iftar" as prescribed, while 5 were drug defaulters. On the first endoscopy the diagnosis in 4 patients was active acute duodenal ulcer (AADU), in 8 patients was active chronic duodenal ulcer (ACDU) in 8 patients was healed duodenal ulcer (HDU), in 2 patients was erosive duodenitis (ED), and in 1 patient was chronic gastric ulcer (CGU). All of the patients with AADU showed signs of healing on repeat endoscopy. None of the ACDU patients showed signs of healing on repeat endoscopy. Instead, 7 patients in this group bled during fasting. All of the 5 drug defaulters belonged to the ACDU group. One patient in the HDU group had developed an active ulcer near the previous scar, as which was seen on repeat endoscopy. The 2 patients with ED showed signs of healing, while the only patient with CGU had bled from the same ulcer as seen on repeat endoscopy. The results were compared with those of 15 nonfasting control subjects (6 patients with ACDU, 3 with HDU, and 6 with ED as diagnosed on the first endoscopy), who took an H(2)-blocker regularly. The repeat endoscopy did not show any change in these patients. In conclusion, we inferred that Ramadan fasting may prove hazardous in patients with peptic ulcer disease in general and with active chronic ulcers in particular, although the fact that only 23 patients volunteered for this study, of whom 5 were drug defaulters, is a limitation.     

Activity monitoring for assessment of physical activities in daily life in patients with chronic obstructive pulmonary disease

OBJECTIVE: To investigate the degree of agreement between different methods of assessing physical activities in daily life in patients with chronic obstructive pulmonary disease (COPD): video recordings (criterion standard), the DynaPort Activity Monitor (DAM), and patient self-report. DESIGN: Study A: outcomes from video recordings were compared with DAM outcomes and with patient estimation of time spent on each activity after a 1-hour protocol including walking, cycling, standing, sitting, and lying. Study B: DAM outcomes and patient self-report were compared during 1 day in real life. SETTING: Outpatient clinic in a university hospital. PARTICIPANTS: Study A: 10 patients with COPD (mean age, 62+/-6 y; forced expiratory volume in the first second [FEV1]=40%+/-16% of predicted). Study B: 13 patients with COPD (mean age, 61+/-8 y; FEV1=33%+/-10% of predicted). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Time spent on different activities and movement intensity during walking and cycling. RESULTS: Study A: time estimated by the patients in the sitting position was significantly lower than the time showed by the video recordings and the DAM (both P<.001). For the other variables, there were no statistically significant differences (all P>.05). However, Bland and Altman plots and intraclass correlation coefficients showed large disagreement between video recordings and patients' estimations, in contrast to the high degree of agreement between video recordings and DAM. Changes in walking speed correlated highly to changes in DAM movement intensity (r=.81, P<.01). Study B: patients significantly overestimated walking time (22+/-47 min, P=.04) and underestimated standing time (-45+/-71 min, P=.04). CONCLUSIONS: The DAM showed high accuracy in objectively assessing time spent on different activities and changes in walking speed in patients with COPD. Patients' estimations of time spent on physical activities in daily life disagreed with objective assessment.     

Impact of medical student preceptorship on ED patient throughput time

A prospective, consecutive study was performed to determine if medical student supervision in the emergency department (ED) changes patient throughput time (ie, the time from triage to discharge). The mean patient throughput time on days when medical students were present in the ED (group 1) was compared to the mean patient throughput time on days when medical students were absent from the ED (group 2). Throughput time was measured in minutes. The mean throughput times of the two groups were compared by the two tailed t test (P < .05). The study had a power of 90% (β = .10) to detect a throughput time difference of 20 minutes. The two groups were also compared for mean daily acuity (as gauged by mean daily number of patient admissions) and mean daily patient census. The differences in mean daily throughput times (group 1, 145.2 min v group II, 150.6 min; P = .40), mean daily census (group 1, 28.1 patients v group 2, 28.1 patients; P = .75), and mean daily admissions (group 1, 10.4 patients v group 2, 10.7 patients; P = .74) were all insignificant. Precepting medical students in this ED did not significantly change patient throughput times.     

Studies of Blood Flow in Aorta-to-Coronary Venous Bypass Grafts in Man

Pressure-flow measurements were obtained from the vein graft of 57 patients undergoing a single aorta-to-coronary bypass procedure.The flow contour was similar to phasic left coronary artery flow in dogs except for a transient increase during systole possibly related to elongation of the graft. Flow was highest during bypass and decreased to a stable value 30 min after bypass. In 42 patients, flow at this time was 35+/-2 cm(3)/min (mean+/-sem).NO CORRELATIONS WERE DEMONSTRATED BETWEEN FLOW AND THE FOLLOWING: left vs. right grafts, presence or absence of collaterals, total vs. partial block, or the presence or absence of ventricular dyskinesis. In 32 patients, no correlation between these anatomic findings and the presence of reactive hyperemia was demonstrated. In 17 patients, occlusion of the graft for 10 sec resulted in a mean 51.5% flow debt repayment.In nine patients, injection of 0.3 mug of isoproterenol into the graft increased flow from 45+/-6 to 69+/-9 cm(3)/min within 4-7 sec without changes in rate, pressure, time derivative of left ventricular pressure (LV dp/dt), or left ventricular end diastolic pressure (LVEDP). Maximum increases to 87+/-10 cm(3)/min occurred 12-20 sec after injection with concomitant changes in these parameters.Intravenous infusion of norepinephrine did not change vascular resistance, whereas phenylephrine did. In six patients, injection of 0.2 mug of norepinephrine into the graft decreased flow from 49+/-6 to 25+/-5 cm(3)/min within 5-8 sec.Intravenous infusion of 0.15 mg of nitroglycerin decreased coronary vascular resistance from 2.7+/-0.4 to 2.3+/-0.3 mm Hg/cm(3) per min. In five patients, 0.12 mg of nitroglycerin injected into the graft increased flow from 46+/-7 to 71+/-13 cm(3)/min and lasted 20-40 sec.     

Local lay rescuers with AEDs,alerted by text messages,contribute to early defibrillation in a Dutch out-of-hospital cardiac arrest dispatch system

Aim

Public access defibrillation rarely reaches out-of-hospital cardiac arrest (OHCA) patients in residential areas. We developed a text message (TM) alert system, dispatching local lay rescuers (TM-responders). We analyzed the functioning of this system, focusing on response times and early defibrillation in relation to other responders.

Methods

In July 2013, 14 112 TM-responders and 1550 automated external defibrillators (AEDs) were registered in a database residing with the dispatch center of two regions of the Netherlands. TM-responders living <1000 m radius of the patient received a TM to go to the patient directly, or were directed to retrieve an AED first. We analyzed 1536 OHCA patients where a defibrillator was connected from February 2010 until July 2013. Electrocardiograms from all defibrillators were analyzed for connection and defibrillation time.

Results

Of all OHCAs, the dispatcher activated the TM-alert system 893 times (58.1%). In 850 cases ≥1 TM-responder received a TM-alert and in 738 cases ≥1 AED was available. A TM-responder AED was connected in 184 of all OHCAs (12.0%), corresponding with 23.1% of all connected AEDs. Of all used TM-responder AEDs, 87.5% were used in residential areas, compared to 71.6% of all other defibrillators. TM-responders with AEDs defibrillated mean 2:39 (min:sec) earlier compared to emergency medical services (median interval 8:00 [25–75th percentile, 6:35–9:49] vs. 10:39 [25–75th percentile, 8:18–13:23], P < 0.001). Of all shocking TM-responder AEDs, 10.5% delivered a shock ≤6 min after call.

Conclusion

A TM-alert system that includes local lay rescuers and AEDs contributes to earlier defibrillation in OHCA, particularly in residential areas.     

Computerized literature searching on a core internal medicine clerkship

The use, acceptance, and benefits of computerized literature searching by medical students during an internal medicine clerkship were evaluated. A year‐long prospective comparison of two student groups was performed in a community‐based medical school with five clinical sites. All third‐year medical students were required to supply two nontextbook references for each assigned patient evaluation during their core medicine clerkship. All 37 students enrolled in the second and fourth quarters of the academic year (Group 1) used the computer bibliographic retrieval service BRS Colleague® through five local modern‐equipped terminals to obtain their references. The 40 students in the first and third quarters (Group 2, controls) obtained their references without doing computer searches themselves. All Group 1 students felt capable of using the system, and 96% felt the service was helpful to their clinical learning. When compared with the control group, students using the computer search spent less time looking for articles (23 min vs. 122 min) and found more useful references about therapeutics. The mean cost per student search was $10.64. These data indicate that computerized literature searching is easily learned, used, and accepted by third‐year medical students. Time is saved accessing the medical literature. Computer literature search training should be an integral part of today's medical student curriculum.     

Does chronic daily headache arise de novo in association with regular use of analgesics?

BACKGROUND: The prevalence of chronic daily headache in association with regular use of analgesics is about 2%. Whether regular use of analgesics has a causal or consequential relationship to daily headache has not been established. A causal relationship has been suggested consequent to the observation of improvement or resolution of headache following analgesic withdrawal in patients attending headache clinics, but this observation has not been validated by controlled trials. PURPOSE: The aim of our investigation was to determine whether regular use of analgesics is associated with the development of chronic daily headache de novo and to characterize the clinical phenotype of those headaches by carefully studying chronic daily headache in patients with regular use of analgesics for a nonheadache indication. METHODS: Patients attending a rheumatology-monitoring clinic of second-line agents were interviewed by a training neurologist with regard to their analgesic and headache history. Headache classification was according to the criteria of the International Headache Society. Daily headache characteristics were surveyed via a standardized questionnaire, and headache features were further explored by a trained medical interviewer. RESULTS: Of 110 patients presenting to a rheumatology-monitoring clinic, 73% had a diagnosis of rheumatoid arthritis, 23% had seronegative arthritis, and 4% comprised a miscellaneous group. One hundred three were using one or more analgesics regularly for their arthritis. Of this group, 8 (7.6%) reported a history of chronic daily headache, each of whom reported a history of migraine. The onset of migraine occurred before the onset of chronic daily headache in 7 patients and at about the same time as the chronic daily headache in 1 patient. In those with onset of migraine prior to chronic daily headache, the mean interval before the onset of headache was 30 years (range, 10 to 50 years). Regular use of analgesics preceded the onset of daily headache in 5 patients by a mean of 5.4 years (range, 2 to 10 years). In 1 patient, analgesic use and the development of daily headache occurred at about the same time. In 1 patient, the onset of daily headache preceded regular use of analgesics by almost 30 years. Five of those with regular use of analgesics had been taking an opiate-based preparation in combination with a nonsteroidal anti-inflammatory agent in 4. Two had been on a combination of acetaminophen (paracetamol) and a nonsteroidal anti-inflammatory drug. The minimum number of tablets per week was 7, and the mean was 48 (range, 7 to 87). Of those patients who did not have daily headache, 41% had a history of migraine and 27% reported a history of tension-type headache. CONCLUSION: These findings suggest that individuals with primary headache, specifically migraine, are predisposed to developing chronic daily headache in association with regular use of analgesics.     

The Impact of a Clinical Information System in an Intensive Care Unit

Purpose Although clinical information systems (CISs) have been available and implemented in many Intensive care Units (ICUs) for more than a decade, there is little objective evidence of their impact on the quality of care and staff perceptions. This study was performed to compare time spent charting with pen and paper patient data versus time spent with the new electronic CIS and to evaluate staff perceptions of a CIS in an ICU. Materials and Methods Time spent every day was calculated for each patient, for 7 days, for recording on the paper vital signs and physician therapeutic orders and time spent for computing fluid balance and scores. This time was then compared with time required to make the same activities by means of CIS, 10 months after its introduction in ICU. Four years after the installation of CIS, a questionnaire was given to all staff attending to the ICU to evaluate their opinions of the CIS. Results The CIS took less staff time to record common ICU data than paper records (3 ± 2 minutes/day versus 37 ± 7 minutes/day respectively, P< 0.001). Perceptions of the CIS were that computers promoted an improving charting quality. Conclusions The implementation of a CIS was associated with a reduced time spent for daily activity and a positive medical and nursing staff perception. Donati A, Gabbanelli V, Pantanetti S, Carletti P, Principi T, Marini B, Nataloni S, Sambo G, Pelaia P. The impact of a clinical information system in an intensive care unit.     

Dissection efficiency during laparoscopic oesophageal dissection

Advanced techniques in laparoscopic surgery have led to an increased need for appropriate training in instrument handling and dissection. Recent developments in computer video technology have facilitated critical analysis of surgical technique. Video deconstruction of oesophageal hiatal dissection during six laparoscopic fundoplication procedures was undertaken. The procedures were performed by surgeons with a wide range of surgical experience, and the investigators analysing performance were blinded to their level of training. Sequential five‐second video segments were analysed in detail by 3 investigators. A taxonomy list was developed to describe individual types of movement. The number and time per movement was assessed and a degree of efficiency was assigned. An efficient movement was defined as one that advances the dissection towards a recognised goal. The total oesophageal dissection time varied from 10?minutes (min) to 25?min (mean 16?min). The mean number of actions performed was 173 (range 120–272). A mean of 7?min was spent separating tissues (range 5–13), with 6?min spent grasping and positioning tissue (range 3–8). The amount of time spent in inefficient movement varied from 3 to 14?min (mean 7?min). The greatest variation between operators was seen in the efficiency of tissue separation when using dissecting instruments. Inexperienced operators spent a lot more time performing additional movements such as scope cleaning, observation and instrument exchange. This technique of video deconstruction can identify key areas for improvement. This could be used for trainee assessment and to provide constructive feedback. Future development in this area could enhance training in advanced laparoscopic techniques.     

Dissection efficiency during laparoscopic oesophageal dissection.

Advanced techniques in laparoscopic surgery have led to an increased need for appropriate training in instrument handling and dissection. Recent developments in computer video technology have facilitated critical analysis of surgical technique. Video deconstruction of oesophageal hiatal dissection during six laparoscopic fundoplication procedures was undertaken. The procedures were performed by surgeons with a wide range of surgical experience, and the investigators analysing performance were blinded to their level of training. Sequential five-second video segments were analysed in detail by 3 investigators. A taxonomy list was developed to describe individual types of movement. The number and time per movement was assessed and a degree of efficiency was assigned. An efficient movement was defined as one that advances the dissection towards a recognised goal. The total oesophageal dissection time varied from 10 minutes (min) to 25 min (mean 16 min). The mean number of actions performed was 173 (range 120-272). A mean of 7 min was spent separating tissues (range 5-13), with 6 min spent grasping and positioning tissue (range 3-8). The amount of time spent in inefficient movement varied from 3 to 14 min (mean 7 min). The greatest variation between operators was seen in the efficiency of tissue separation when using dissecting instruments. Inexperienced operators spent a lot more time performing additional movements such as scope cleaning, observation and instrument exchange. This technique of video deconstruction can identify key areas for improvement. This could be used for trainee assessment and to provide constructive feedback. Future development in this area could enhance training in advanced laparoscopic techniques.