Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance

• Published in: Journal of surgical education Vol. 76; no. 5; pp. 1303 - 1308
• Main Authors: Kucera, Walter, Nealeigh, Matthew, Franklin, Brenton, Bowyer, Mark, Sweeney, W. Brian, Ritter, E. Matthew
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2019
• Subjects: Education; Error-management training; Error-recognition training; Fasciotomy; Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Patient Care; Education; Medical Knowledge; Practice-Based Learning and Improvement; Fasciotomy; Error-management training; Error-recognition training
• ISSN: 1931-7204; 1878-7452
• DOI: 10.1016/j.jsurg.2019.03.003

Many injuries from recent wars involve extremity trauma secondary to blasts, which predispose patients to developing extremity compartment syndrome. In military studies, 17% of fasciotomies required revision on arrival to a Role 4 hospital, and 41% of these had missed compartments, which is similar to that seen in civilian centers. While training has decreased this rate to 8%, this number is still too high. We conducted a focused needs assessment to guide the development of lower-extremity fasciotomy training. In a predeployment assessment, 42 military surgeons performed a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models. Models were assessed for standardized and objectively-assessed major (inadequate skin or fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on joint Trauma System clinical practice guidelines and approved training curricula. Four of 42 (9.5%) models contained no errors. Models averaged 4.3 ± 2.6 major and 0.3 ± 0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most common missed compartments were the deep posterior (17%) and anterior (14%). 29 (69%) had inadequate or poorly-placed skin incisions, with the most common being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). A total of 36 (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%), and deep (34%) posterior compartments Performance on the models approximates what has been seen in military and civilian settings. This needs assessment will inform development of a simulation curriculum based on error-management and mastery learning theory to reduce the morbidity of lower-extremity compartment syndrome.