A Novel Cast Removal Training Simulation to Improve Patient Safety

OBJECTIVE: Cast application and removal are essential to orthopedics and performed by providers of variable training. Simulation training and practice of proper cast application and removal may reduce injury, optimize outcomes, and reduce health care costs. The purpose of this educational initiative was to develop, validate, and implement a novel simulation trainer and curriculum to improve safety during cast removal. METHODS: In all, 30 thermocouples (Omega, Stamford, CT) were applied to a radius fracture model (Sawbones, Vashon, WA). After reduction and cast application, a saw (Stryker, Kalamazoo, MI) was used to cut the cast with temperature recording. Both "good" and "poor" techniques as established by consensus best practices were used. Maximal temperatures were compared to known thresholds for thermal injury; humans experience pain at temperatures exceeding 47 degrees C and contact temperatures exceeding 60 degrees C may lead to epidermal necrosis. Construct validity was evaluated by assessing novice (postgraduate year 1), intermediate (postgraduate year 3), and expert (pediatric orthopedic attending) performance. RESULTS: With the "good" technique, mean peak temperatures were 43 degrees C + 4.3 degrees C. The highest recorded was 51.9 degrees C. With the "poor" technique, mean peak temperature was 75.2 degrees C + 17.3 degrees C. The maximum temperature recorded with the "poor" technique was 112.4 degrees C. Construct validity testing showed that novices had the highest increases in temperatures (12.9 degrees C). There was a decline in heat generation as experience increased with the intermediate group (9.7 degrees C), and the lowest heat generation was seen in the expert group (5.0 degrees C). CONCLUSIONS: A novel task simulator and curriculum have been developed to assess competency and enhance performance in the application and removal of casts. There was a 32.2 degrees C temperature decrease when the proper cast saw technique was used. Furthermore, the "poor" technique consistently achieved temperatures that would cause epidermal necrosis in patients. Clinical experience was a predictor of decreased heat generation during cast removal. This task trainer allows instruction and safety monitoring of the casting technique. ((C) 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)