Impact of a simulation-based induction programme in gastroscopy on trainee outcomes and learning curves

Table 1 The Structured PRogramme of INduction and Training gastroscopy induction programme

Time	Programme
8.3	Coffee and registration
9	Welcome and introduction to aims and objectives
9.3	Simulator session 1	Basic handling and scope design
10.2	Basic handling and scope design	Simulator session 1
11.1	Coffee
11.3	Simulator session 2	JAG Certification, appraisal and training lists
12.2	JAG Certification, appraisal and training lists	Simulator session 2
13.1	Lunch
13.4	Simulator session 3	Enhancing the endoscopic image
14.1	Enhancing the endoscopic image	Simulator session 3
15	Coffee
15.2	Simulator session 4	Lesion recognition and assessment skills 1
16.1	Lesion recognition and assessment skills 1	Simulator session 4
17	Round up
8.3	Coffee and registration
9	Welcome and introduction to day 2
9.1	Simulator session 5	Getting the best out of the JETS e-portfolio
10	Getting the best out of the JETS e-portfolio	Simulator session 5
10.5	Coffee
11.1	Simulator session 6	Lesion recognition and assessment skills 2
12	Lesion recognition and assessment skills 2	Simulator session 2
12.5	Lunch
13.2	Simulator session 7	Decision-making and report writing
13.5	Decision-making and report writing	Simulator session 7
14.4	Coffee
15	Simulator session 8	DOPS assessment and improving your skills
15.5	DOPS assessment and improving your skills	Simulator session 8
16.4	Summary and review of course objectives

DOPS: Direct observation of procedural skills.

Table 2 Comparisons of module-dependent EndoSim metrics between trainees (stratified into novice and intermediate experience groups) and faculty members

Module	Metric	Median (IQR)		P value (Expert vs trainee)	Median (IQR)		P value (Novice vs intermediate)
		Expert (n =6)	Trainee (n = 20)		Novice trainee (n = 10)	Intermediate trainee (n = 10)
Module 1: Wheel Handling (4 stations)	Missed targets	3 (1-4)	6 (3-8)	< 0.001	7 (4-9)	6 (2-8)	0.057
	Wheel rotation left/right (Degrees)	257 (42-382)	143 (5-591)	0.463	82 (1-643)	166 (9-575)	0.753
	Wheel rotation up/down (Degrees)	783 (691-916)	764 (606-1173)	0.903	680 (442-1005)	1023 (687-1303)	0.003
	Endoscope rotation (Degrees)	1398 (749-2355)	964 (353-1577)	0.025	886 (350-1404)	1044 (349-1955)	0.350
Module 2: Navigation (3 stations)	Total time (s)	74 (52-104)	104 (79-166)	0.002	161 (108-218)	82 (67-105)	< 0.001
	Wheel rotation left/right (Degrees)	109 (40-305)	138 (3-757)	0.826	391 (3-1648)	99 (2-549)	0.143
	Wheel rotation up/down (Degrees)	888 (680-1108)	1232 (934-1868)	0.001	1268 (958-1737)	1224 (931-2046)	0.641
	Endoscope rotation (Degrees)	1120 (933-1865)	1770 (1313-2334)	0.007	1847 (1258-2571)	1722 (1357-2258)	0.503
	Endoscope tip path length (cm)	228 (179-306)	324 (251-411)	0.002	357 (280-489)	280 (239-356)	0.028
Module 3: Button Handling (3 stations)	Missed targets (number)	2 (0-4)	2 (1-4)	0.623	2 (1-5)	1.5 (1-4)	0.805
	Unnecessary button presses (number)	2 (0-4)	2 (1-4)	0.270	2 (1-5)	2 (1-4)	0.963
	Missed dirt (number)	1 (1-2)	1 (1-2)	0.944	1 (0-2)	1 (1-2)	0.429
Module 4: Photo (4 stations)	Total time (s)	151 (121-192)	313 (230-377)	< 0.001	328 (235-404)	269 (179-361)	0.054
	Stomach visualized (%)	93% (79%-99%)	100 (96%-100%)	< 0.001	99% (94%-100%)	100% (97%-100%)	0.070
	Duodenum visualized (%)	63% (52%-74%)	63% (53-72%)	0.855	62% (51%-68%)	66% (58%-74%)	0.088
	Collisions against mucosa (number)	8 (5-12)	13 (9-16)	< 0.001	13 (11-20)	12 (8-15)	0.090
	Targets photographed (%)	100% (100%-100%)	100% (100%-100%)	0.495	100% (100%-100%)	100% (100%-100%)	0.302
Module 5: Biopsy (3 stations)	Total time (s)	182 (163-217)	340 (249-463)	< 0.001	446 (331-522)	299 (215-389)	0.001
	Targets biopsied	100% (100%-100%)	100% (50-100%)	0.010	100% (38%-100%)	100% (50%-100%)	0.546
	Biopsies outside any target (number)	0 (0-2)	4 (2-9)	< 0.001	3 (2-8)	4 (2-11)	0.548
	Collisions against mucosa (number)	7 (4-11)	9 (7-13)	0.030	12 (9-23)	7 (6-11)	< 0.001
	Movement with tool (cm)	25 (17-53)	72 (36-183)	0.002	73 (29-183)	70 (42-179)	0.910

Data are presented as medians (interquartile ranges), with P values derived from Mann-Whitney tests. Bold P values are significant at P < 0.05. IQR: Interquartile ranges.

Table 3 Self-reported scores pre- and post-course

Skill	Median confidence score (IQR)		P value
	Pre-course	Post-course
Tip control	5 (2-7)	8 (7-9)	< 0.001
Torque steering	5 (2-6)	8 (7-9)	< 0.001
Intubation	3 (0-7)	7 (6-9)	< 0.001
Oesophagus to pylorus	5 (1-8)	9 (7-9)	< 0.001
Pyloric intubation	4 (0-7)	8 (7-9)	< 0.001
D2 intubation	3 (0-6)	7 (5-9)	< 0.001
Duodenal withdrawal	4 (0-7)	8 (5-9)	< 0.001
J manoeuvre	5 (1-8)	8 (7-9)	< 0.001
Retroflexed views	5 (2-7)	8 (6-9)	< 0.001
Overall visualisation	5 (2-7)	8 (7-9)	< 0.001
Image taking	4 (1-6)	8 (7-8)	< 0.001
Use of accessories	3 (0-5)	8 (6-9)	< 0.001

Analysis is based on the n = 20 who attended the course. P values are from Wilcoxon’s tests, with bold P values significant at P < 0.05. IQR: Interquartile range.

Table 4 Generalised estimating equation models of procedure outcomes in cases and controls

	Cases		Controls		P value (Case vs Control)
	Odds ratio (95%CI)	P value	Odds ratio (95%CI)	P value
Unassisted D2 intubation rates
Intercept	0.51 (0.13 – 1.98)	-	-	-	0.332
Gradient (per Doubling of OGD count)	1.99 (1.69 – 2.34)	< 0.001	1.74 (1.53 – 1.98)	< 0.001	0.205
Moderate-severe discomfort
Intercept	0.42 (0.15 - 1.15)	-	-	-	0.09
Gradient (per 10 procedures)	0.97 (0.88 - 1.07)	0.526	0.92 (0.85 - 1.00)	0.044	0.421
Unsedated procedures
Intercept	1.63 (1.09 – 2.46)	-	-	-	0.018
Gradient (per 10 procedures)	0.99 (0.97 – 1.01)	0.28	1.00 (0.98 – 1.02)	0.973	0.445

Results are from generalised estimating equation models of the 200 procedures after the date of the course for each trainee. Each model contained the trainee group (case-control) and the procedure number as covariates, along with an interaction term. As such, the intercept represents the baseline difference between the case and control groups. The gradient represents the change in the outcome rate with increasing experience, with separate gradients reported for the case and control groups. For unassisted D2 rates, the procedure number was log-transformed in the model, hence the resulting coefficients were anti-logged, and gradients were reported per two-fold increase in procedure count. For the discomfort and unsedated procedures outcomes, gradients are reported per 10 additional procedures. The final column compares the gradients between groups, using the P value from the interaction term in the model. Bold P values are significant at P < 0.05.