Suggested OSCEs for Modules A, B, C and D
A1 Evaluation
Section 1.
· This student maintained sterile technique during the procedure (25 points).
· Touched n non sterile item or area, acknowledged occurrence and readily offered a solution to the break in technique (first offense 0 points, second offense minus 5 points, and each additional offense minus 5 points).
· Did not acknowledge gross-contamination of fingers, hands, or arms while performing this procedure (“failed”).
· The following are considered serious breaches of hygiene rules: Face-masks being allowed to hang down after use; using the hands to handle a used face-mask (minus 5 points).
Section 2-4.
· This student maintained sterile technique during the procedure (25 points).
· Touched a non sterile item or area, acknowledged occurrence and readily offered a solution to the break in technique (first offense 0 points, second offense minus 5 points, and each additional offense minus 5 points).
· Did not acknowledge gross-contamination while performing this procedure (“failed”).
Sections 5-7.
Students should perform the whole procedure in the right order and with maximal compliance with the rules of sterility (25 points). Typical mistakes (minus 3 points/mistake):
· Sterility is broken.
· The direction of scrubbing is not proper.
· The order of scrubbing is not proper.
· Returning to a cleansed area with the same sponge.
· The order of draping is not proper.
· Drapes are moved toward the sterile field.
· Fixation with Backhaus towel clips is not proper.
A2 Evaluation
Sections 1-4.
Identify instruments by proper name and classify instruments into categories. Example: write the proper name of each instrument displayed and include descriptive nouns such as the words “SCISSORS” or “CLAMP”, etc. Classify the instrument by choosing the correct category. Place the category title or abbreviation listed below next to each instrument (e.g. CD = cutting/dissecting, W = wound closing, R = retracting/exposing).
Section 1-4.
· The student is able to use an instrument (5 points).
· Typical mistakes (minus 1 point/mistake): holding the scalpel or the scissors with an overhand grip; the blade is grasped during the incision; the handle is grasped far from the blade; the forceps is held incorrectly; using index finger and thumb in the finger holes of the needle holder causes loss of control; holding the needle too near to its tip; holding the needle too near its French-eyed end may cause the buckling or snapping of the needle, etc.
A3 Evaluation (Sections 1-6)
· The knots are correctly tied, they are not loose or too tight (30 points).
· Incorrectly tied knot (- 5 points each): the treads are not crossed, the knot is loose, the knot is too tight, only one double knot is tied with a monofilament synthetic suture, etc.
A4-5 Evaluation
The suturing skills of the students are assessed by using the following checklist which consists of 18 task steps (instructions to candidates: suture the clean incised wound with interrupted sutures).
Item
Done correctly Not done correctly 1.
Selects appropriate suture, needle holder and forceps 1 0 2.
Needle loaded 1/2 to 2/3 from tip 1 0 3.
Bite distance from the skin edge: 5 mm 1 0 4.
Angle at which bite is taken: 900 1 0 5.
Single attempt while taking bites in the skin. 1 0 6.
Movement occurs at wrist 1 0 7.
Suture board moves or not 1 0 8.
Forceps used to hold skin or sc. tissues (minimum use) 1 0 9.
Takes bites from both skin edges in one go/separately 1 0 10.
Equal bites on both sides 1 0 11.
Whether needle is touched with hand 1 0 12.
Number of knots taken 1 0 13.
Knot is square or not 1 0 14.
Knot is too tight or too loose 1 0 15.
Distance between neighboring stitches: 0.5 to 1 cm 1 0 16.
Knot is on the incision line or on one side 1 0 17.
Skin edges are averted or inverted 1 0 18.
Suture breaks or not 1 0 Maximum total score (18)
A6 Evaluation
Sections 1-2.
· This student maintained sterile technique during procedure; dressings/procedures were applied correctly (25 points).
· Touched a non sterile item or area, acknowledged occurrence and readily offered a solution to the break in technique (first offense 0 points, second offense minus 5 points, and each additional offense minus 5 points).
Sections 3-6.
· Dressings/procedures were applied correctly (20 points).
· Indications for wound management procedure are not known (minus 5 points).
· Steps of wound management procedure are incorrect (minus 5 points)
· Bandage is loose/applied incorrectly (minus 5 points)
B1 Evaluation
Section 1.
The student should keep the general rules of giving injections (5 points), and he/she should perform an IC. (5 points), a sc. (5 points), an im. (5 points), and an IV. Injection (5 points) as described (total: 25 points). Typical errors (minus 1 point each):
· General rules: hand wash and/or gowning is not performed; asepsis is not maintained (rubber stop of the vial or skin is not disinfected properly; the sterility of the syringe and needle is broken etc.); the needle is not changed after the suction of the drug; air is not removed from the syringe.
· Injection techniques: not the appropriate syringe and/or needle are selected; the technique of the injection is not correct; it is given in an improper tissue or layer; the site of the injection is not controlled; no tamponade is used after removal.
Section 2.
The student should unwrap the needle or braunule set, and he/she should introduce the needle or catheter observing the rules of asepsis during the entire procedure (10 points). Typical errors (minus 1 point each):
· Hand wash and/or gowning is not performed; mistakes in maintaining asepsis (the injection site is not disinfected properly, sterility of the devices is broken, etc.); the technique of the injection/cannulation or the removal of the needle/catheter is not correct; the needle/cannula is not introduced IV. or punctures the posterior wall of the vein; the site of the needle/braunule is not controlled after introduction; the needle/cannula is not fixed; no tamponade with an alcoholic sponge is used after removal.
Section 3.
The student should imitate blood sampling on the phantom hand after the needle/catheter has been introduced IV. (5 points). Typical errors (minus 1 point each):
· Sterility is broken; the needle is not fixed with one hand during the procedure; the tubes are changed in incorrect sequence; the dilution of the samples is not correct; the samples are not mixed with the anticoagulant.
Section 4.
The student should unwrap, assemble and connect the infusion set to the IV. Catheter under aseptic conditions, and he/she should adjust the flow rate (5 points). Typical errors (minus 1 point each):
· Sterility is broken during the procedure; the set is improperly assembled; the fluid level in the drip chamber is too low or high; the air is not expelled from the tubing; the flow rate is not adjusted; the tubing is not fixed.
B2-3 Evaluation
Sections 1-2.
· The student is able to perform the whole procedure in the right order and with maximal compliance with the rules of sterility (20 points).
· Typical mistakes (minus 2 points/mistake): sterility is broken; the direction and depth of puncture is not proper, improper grasping of the braunule, impossible to introduce the flexible guide-wire into the cannula, ccatheter fixation is not proper because the ligature is too loose, etc.
B4 Evaluation
· Properly performed measurements/imaging and recording (15 points).
B5 Evaluation
Section 1.
· Correctly performed endotracheal intubation (40 points)
· Damage to the teeth with the laryngoscope (pressure on the teeth is indicated by an acoustic signal in the head model) (- 10 points)
· Tracheal damage or injuries to surrounding areas during insertion of the tube (- 5 points)
· Tube is inserted into esophagus (a buzzer is sound in the head model) (- 10 points)
· Endotracheal tube is inserted very deeply (under the tracheal bifurcation) (- 5 points)
· Over inflation of the cuff (pressure damage) (- 10 points).
Sections 2. and 3.
· Correctly performed measurements (10 points)
· Imperfect connection (leaking) between the capnograph line and the endotracheal tube leading to incorrect measurements (- 5 points)
· Measurements are impossible due to incorrectly placed oximeter sensors (- 5 points)
Section 4.
· Properly performed blood sampling (15 points)
· Improper use of stopcocks during sampling (- 10 points)
· Sampling without discarding the first drops of blood (- 5 points)
· Blood sampling into a nonheparinized syringe (- 15 points)
· Air bubbles in the blood sample (- 5 points)
· Omission of flushing the catheter with saline (- 5 points)
Section 5.
· Properly performed analysis (15 points)
· Omission of mixing the blood sample immediately before analysis (- 10 points)
· Performing blood gas analysis without discarding the first drops (- 5 points)
Section 6.
· Proper use and changing the respirator settings (15 points)
· Improper connection between the respirator and the endotracheal tube or the tracheotomy tube (- 15 points).
B6 Evaluation
Section 1.
9 points can be given if the entire process is performed correctly. Minus points if any of the steps misses or is performed wrong or the process is not in accordance with the rules of asepsis.
Section 2.
4 points can be given if the entire process is performed correctly. Minus points if any of the steps misses or is performed wrong. It is a serious mistake if the fluid is not removed from the balloon.
Section 3.
9 points can be given if the entire process is performed correctly. Minus points if any of the steps misses or is performed wrong or the process is not in accordance with the rules of asepsis.
Section 4.
4 points can be given if the entire process is performed correctly. Minus points if any of the steps misses or is performed wrong. Serious mistake if the fluid is not removed from the balloon.
C1-2 Evaluation
Section 1.
· The student is able to perform the whole procedure in the right order and with maximal compliance with the rules of sterility (25 points).
· Typical mistakes (minus 5 points/mistake): sterility is broken; anesthetic infiltration is forgotten; the direction and length of the incision is not proper; problems with instrument handling during wound closure.
Section 2.
· The student is able to perform the whole procedure in the right order and with maximal compliance with the rules of sterility (25 points).
· Typical mistakes (minus 5 points/mistake): sterility is broken; anesthetic infiltration is forgotten; the direction and length of incision is not proper (typically the width of the excised ellipse is too big, and its depth is too small); problems with instrument handling during wound closure; wound closure and knotting problems due to tension of the wound.
Section 3.
· The student is able to perform the whole procedure in the right order and with maximal compliance with the rules of sterility (25 points).
· Typical mistakes (minus 5 points/mistake): sterility is broken; anesthetic infiltration is forgotten; the direction and length of incision is not proper; problems with instrument handling during wound closure.
Section 4.
· The student is able to perform the whole procedure in the right order and with maximal compliance with the rules of sterility (25 points).
· Typical mistakes (minus 5 points/mistake): steps (e.g. emptying the lumen, temporary closure of the bowel, disinfection of the lumen) are missing; enterotomy is not performed by electrocautery, but with scalpel; approximation of the bowel wound edges is performed not perpendicular to the enterotomy; problems with the patency of the anastomosis.
C3-4 Evaluation
Section 1.
The students (in surgeon’s, assistant’s and scrub nurse’s role) should perform scrub preparation of their hands, gowning and gloving, scrub preparation and draping of the operative field, surgical exposure of the linea alba below the umbilicus, introduction of the lavage catheter, DPL, removal of the catheter and wound closure. (25 points in each role). Students should be able to work in each role. Typical errors (minus 1 point each)
· Errors in the aseptic technique. Unrecognized, uncorrected mistakes in the following:
o putting on caps, masks, shoe covers;
o mechanical scrub preparation and disinfection of hands;
o gowning and gloving;
o behavior and movement in the operating room;
o scrub preparation and draping of the surgical area;
o maintaining asepsis during operation.
· Errors in the surgical technique:
o incorrect position at the operating table;
o use of inadequate instruments (e.g. dressing forceps for grasping skin and linea alba instead of tissue forceps or Backhaus clamps, general purpose scissors instead of Mayo scissors for blunt dissection, etc.) or materials (e.g. muscle needle and thin thread for suturing skin wound);
o incorrect handling and passing of instruments;
o errors in tying knots (e.g. no square knots are tied, knots are too loose or too tight, etc.);
o errors in skin incision (e.g. skin is not stabilized; cutting is too long, too short, too superficial or too deep, several parallel superficial incisions are made, etc.);
o errors in dividing sc. tissue (e.g. cutting is done with scissors instead of diathermy, the incision does not reach the linea alba, etc.);
o bleeding is not handled adequately;
o errors in the introduction of lavage catheter (e.g. the trocar is not removed from the catheter after it has entered the peritoneal cavity, the end of the catheter is not introduced toward the sacrum, it is not checked before the lavage whether blood can be sucked from the peritoneal cavity);
o errors in the lavage (e.g. the volume and temperature of the washing fluid or the equilibration time is not appropriate, during the collection of the washing fluid, the infusion bag is not lowered below the level of the operating table);
o the catheter is removed before 30% of the infused volume has been recovered;
o errors in wound closure (e.g. the skin stitches are not placed properly, the wound edges are everted or inverted, the knots are tightened very much, the wound is not disinfected, etc.).
Section 2.
The student should perform TPL under aseptic conditions as described above (5 points). Typical errors (minus 1 point each):
· Sterility is broken during the procedure.
· The set is improperly assembled (the temperature of the dialyzing solution is not controlled; the three-way stopcock is not handled properly; the flow rate regulator is not opened, etc.);
· During the removal of the dialyzing fluid, the collecting sack is not placed on the floor.
Section 3.
The students (in surgeon’s, first and second assistant’s and scrub nurse’s role) should perform scrub preparation of their hands, gowning and gloving, scrub preparation and draping of the operative field, middle median laparotomy, inspection of abdominal organs and closure of the abdominal wound in three layers in an anesthetized pig under aseptic conditions (40 points in each role). Students should be able to work in each role. Typical errors (minus 1 point each):
· Errors in the aseptic technique (see Section 1).
· Errors in the surgical technique (see Section 1), including:
o errors in connection with the opening of the peritoneal cavity (during cutting, the linea alba is not elevated, the rectus sheets are severed, the incision exceed the corners of the sc. wound; the peritoneum edges are not clamped with Mikulicz clamps, the jaws of the Gosset self-retaining compresses abdominal organs to the abdominal wall, etc.);
o the abdominal organs are not handled gently (no saline moistened laparotomy sponges are used to protect them from drying out);
o errors in wound closure (e.g. the suture is not secure, the suture is loose because the assistant does not keep the thread under continuous tension during suturing; the sc. stitches does not involve the deeper layer of the sc. wound and a dead space is formed, the sc. stitches are too close to the edges of the skin wound, the skin stitches are not placed properly, the wound edges are everted or inverted, the knots are too tight, the wound is not disinfected, etc.).
Section 4.
The students (in surgeon’s, first assistant’s and scrub nurse’s role) should perform scrub preparation of their hands, gowning and gloving, scrub preparation and draping of the operative field, tracheostomy, insertion of a tracheostomy tube and closure of the skin wound in an anesthetized pig under aseptic conditions (40 points in each role). Students should be able to work in each role. Typical errors (minus 1 point each):
· Errors in the aseptic technique (see Section 1.).
· Errors in the surgical technique (see Section1), including:
o errors in connection with tracheostomy and insertion of the tracheostomy tube (e.g. the incision is made between the cricoid and first tracheal cartilages; the cuff of the tracheostomy tube is not tested for leakage before introduction; the air is not sucked off from the cuff of the endotracheal tube before withdrawal; the retracting stitches are placed very close to the edges of the cut cartilage and they are torn out; the obturator is not removed from the tube after insertion, the cuff is not inflated, etc.);
o errors in wound closure (e.g. the skin stitches are not placed properly, the wound edges are everted or inverted, the wound is not disinfected, etc.).
Section 5.
The students (in surgeon’s, first assistant’s and scrub nurse’s role) should perform scrub preparation of their hands, gowning and gloving, scrub preparation of the site of the intervention, insertion and fixing of a chest tube, removal of the tube and closure of the skin wound with a U-stitch in an anesthetized pig under aseptic conditions (25 points in each role). Students should be able to work in each role. Typical errors (minus 1 point each):
· Errors in the aseptic technique (see Section 1).
· Errors in the surgical technique (see Section 1), including:
o errors in connection with skin incision (e.g. skin is not stabilized; cutting is made at the lower margin of the rib, or not at the standard sites of chest tubing; its length or depth is not appropriate, parallel superficial incisions are made, etc.);
o the parietal pleura is stabbed at the lower, and not at the upper costal margin;
o the outer end of the chest tube is not closed with a Péan hemostat;
o the tube is introduced to an inadequate direction or site;
o it is not fixed, or the way of fixing is inappropriate (no U-stitch is placed around the entry of the tube, or it is not winded up on a sponge; the U-stitch is pulled out);
o the wound is not disinfected, etc.
C5-6 Evaluation
Section 1.
It is based on parameters that permit quantitative evaluation of different components of coordination skills. The student passes the exam if meets the statistical requirements (duration, coordination, avoid tissue damage) calculated by the software of the simulator program (see there).
D1 Evaluation
Section 1.
Position at the operative microscope is appropriate (+ 10 points).
Section 2.
The instruments are held in a pen position during all procedures and elbows are supported (+10 points).
Section 3.
Lacing a thread of gauze net is performed within an optimal time interval, the gauze net is not disorganized. Trembling is reduced (+ 10 points).
Section 4.
Suturing of the rubber pad is performed within an ideal and equal distance from the incision. The stitches are performed in even distances. At least 10-10 stitches are performed into vertical, horizontal and right and left oblique incisions within 2 hrs (+ 10 points).
Section 5.
Microsurgical knotting is perfectly performed within 30 sec. The direction of threads is perpendicular to the incision. Knots are not loose (+ 15 points).
Section 6.
The student is able to apply the skills learned with planar stitching at 3 dimensional tubular structures. The order of stitches is correct; the distances are equal (+ 20 points).
Section 7.
The student is able to overcome the capillary tension on the fine sutures, stickiness of the ex vivo vessels. Does not let the vessel dry out. The stitch bites are equal and the vessel anastomosis is patent. When the vessel is cut longitudinally, the stitch bites appear equally deep and always include the intima layer (+ 40 points).
D2 Evaluation
Section 1. At the end-to-end in vivo vessel anastomosis, the final results should meet the requirements listed in Section 7 of D1 Module. In addition, the student should be able to prepare the vessel without causing any trauma and perform a patent anastomosis without considerable amount of bleeding. In the ideal case, the student is able to perform anastomosis of both carotid arteries in 2 hrs.
Section 2. The student is able to prepare the sciatic nerve and to perform the anastomosis on the nerve in vivo using epineurial technique. The completed anastomosis should not be under any tension whatsoever. Enough stitches are placed to eliminate excessive epineurial gaps and no protruding axons exist between stitches.
General mistakes
o The student does not use both of his eyes under the microscope.
o Injures the instruments.
o Injures the structure ought to be prepared.
o Tears and looses the thread.
Zoltan Szabo, Ph.D.,F.I.C.S.
MOET Institute, San Francisco