gms | German Medical Science

Background: Endovascular procedures have become frequent in vascular surgery and urge new training strategies for future specialists and teams. Simulation-based education (SBE) may be a way to ensure a standardised acquisition of skills [1].

Most SBE-programs focus on training physicians [2], [3], [4], although safe and efficient surgical procedures require a high-performance team, including nurses, physicians and anesthesiologists. It has been shown that team-based training improves both technical and non-technical skills such as communication [5]. Stress impairs performance as well as the learning process [6], [7], [8].

Heart rate variability (HRV) is impacted by stress through sympathetic nervous system, and an association between HRV and surgical performance has been suggested [9], [10].

This study aimed to assess how SBE of endovascular nurse assistants (EVA) affects team performance and HRV as a surrogate of mental stress during endovascular aneurysm repair (EVAR). In addition, the feasibility of implementing SBE of EVAs, including perioperative capturing of errors, and use of wireless ECG monitors, was investigated.

Methods: Between January and June 2020, eight EVAs with no EVAR experience but familiar with lower limb endovascular procedures were invited to follow a systematic SBE program. The SBE consisted of one hands-on session demonstrating the EVAR equipment and explaining steps of the EVAR procedure. Subsequently, the EVAs were trained on the Simbionix Angio Mentor Express System. The SBE program focused on a standard-EVAR procedure and was facilitated by an experienced EVAR operator and a technical assistant. Before and after the SBE program, the EVAs were observed during real-life EVAR-procedures.

HRV was recorded with wireless ECG-plasters and assessed with the square root of the mean of the sum of differences in RR-intervals (RMSSD) and the standard deviation of RR-intervals (SDNN) [9], [10]. The operating team was observed as a measure of team performance, and errors were captured and categorised with the validated Imperial College Error CAPture (ICECAP) tool [11].

Results: Seven out of eight EVAs completed the SBE (88%). In five out of seven EVAs (71%), lower HRV-derived levels of stress were observed during EVAR procedures after SBE, as compared to before SBE (Table 1 [Tab. 1] and Figure 1A [Fig. 1]). Before SBE, the mean number of errors was 7.3 (SD ±1.8) errors/hours compared to 3.6 (SD ±2.7) errors/hour after SBE (Figure 1B [Fig. 1]). The most common errors were categorised as technical (59%) or communicative errors (18%).

Conclusion: Systematic SBE of EVAs improves both team performance and lowers mental stress during EVAR procedures. The SBE program was well-accepted by the EVAs, as well as the perioperative observation of errors and the use of ECG monitors. This study supports HRV as an assessment of mental stress during surgical procedures and ICECAP as a proxy of acquired skills and the effects of SBE, but larger studies are needed.