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The effect of cognitive task analysis based instruction on surgical skills expertise and performance
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The effect of cognitive task analysis based instruction on surgical skills expertise and performance
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Content
THE EFFECT OF COGNITIVE TASK ANALYSIS BASED INSTRUCTION ON
SURGICAL SKILLS EXPERTISE AND PERFORMANCE
by
Leslie A. Tirapelle
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2010
Copyright 2010 Leslie A. Tirapelle
ii
DEDICATION
This dissertation is dedicated to my parents, Wesley and Diane D’aranjo, my
husband, Robert, and our children, Ryan, Tyler and Ellen, who have been there for me
every step of this incredible journey. Your love and support has been priceless, and I am
so thankful for everything you have done for me.
iii
ACKNOWLEDGMENTS
My primary thanks go to Dr. Richard Clark, without whom this journey would not
have been possible. Thank you to the other members of my committee, Dr. Kenneth
Yates and Dr. Maura Sullivan, for coordinating the study details and for always being
available during the dissertation process. I would like to extend thanks to my editor,
Michele Dunbar, for the helpful comments and insights on my dissertation. Particular
thanks go to Julia Campbell, Maryann Tolano-Leveque, Joon Kim and the staff of the
Pasadena City College Shatford Library whose support and friendship were invaluable.
Thank you to my parents who have always fully supported all of my academic endeavors.
To my husband, Robert, thank you for caring for our children as I sat in classes and at the
computer for hours on end -- my success was dependent on your immense support and
understanding. Finally, I would like to thank my children, Ryan, Tyler and Ellen, whose
support and pride have made this all worthwhile.
iv
TABLE OF CONTENTS
Dedication ii
Acknowledgments iii
List of Tables vi
List of Figures vii
Abstract viii
Chapter 1: Introduction and Review of the Literature 1
Introduction 1
Statement of the Problem 2
Cognitive Task Analysis 3
Purpose of the Study 3
Research Questions and Hypotheses 4
Review of the Literature 5
Current Surgical Training and Assessment Methods 5
Apprenticeship Model 5
Standardized Curriculum 6
Performance Assessment 8
Instructional Variation and the Effects on Expertise 9
Types of Knowledge 11
Declarative Knowledge 11
Procedural Knowledge 12
Cognitive Task Analysis 12
The Concepts, Processes & Principles Protocol 13
Instructional Design Informed by CTA 15
Evidence of CTA Effectiveness Outside of Medicine 16
Evidence of CTA Effectiveness in Medicine 17
Conclusion 21
This Study 21
Chapter 2: Method 23
Study Design 23
Participants and Recruitment 24
v
CTA Procedure 25
Study Procedure 30
Data Analysis 32
Chapter 3: Results 33
Participant Group and Pre-test Analyses 33
Pre-test Performance of Declarative Knowledge 34
Overall Post-test Performance 35
Conclusion 37
Chapter 4: Discussion 38
Limitations 40
Unscripted Instruction 40
Participant Behavior 41
Simulated Performance 42
Summary 43
Conclusion 44
References 45
Appendices
Appendix A: Participant Demographic Data Survey 50
Appendix B: CTA Gold Standard for Open Cricothyrotomy 51
Appendix C: Instructor Script Lesson 65
Appendix D: Job Aid for Experimental Group Participants 76
Appendix E: Pre-Test Instruments 85
Appendix F: Surgical Skills Procedural Checklist 89
Appendix G: Post-Test Instruments 95
Appendix H: Statistical Analysis of Participant Data 101
vi
LIST OF TABLES
Table 1: Distribution of Assessment Instruments 29
Table 2: Participant Distribution in Study Groups 34
Table C-1: Lesson Overview 65
Table F-1: Checklist Scenario 1 90
Table F-2: Checklist Scenario 2 93
Table H-1: Univariate Anova: Tests Between Subject Effects 101
Table H-2: T-Test of Independent Means for Total Correct on Pre Test 102
Table H-3: T-Test of Independent Means for Total Correct on Post Test 103
Table H-4: T-Test of Independent Means for Declarative Knowledge
on the Written Post Test 104
Table H-5: T-Test of Independent Means for Procedural Knowledge
on the Surgical Skills Procedural Checklist 105
Table H-6: T-Test of Independent Means for Procedural Knowledge
on the Written Post Test 106
vii
LIST OF FIGURES
Figure D-1: Open Cricothyrotomy Task List 76
Figure D-2: Cricothyrotomy Kit 78
Figure D-3: Vertical Incision 80
Figure D-4: Horizontal Incision 81
Figure D-5: Bag patient while ventilator is set up 83
Figure D-6: Place tracheostomy collar around the neck and suture the collar 84
viii
ABSTRACT
Cognitive Task Analysis (CTA) is a method of eliciting knowledge from experts
that can inform more comprehensive instructional support materials for novices. The
traditional lecture model that places the expert in the role of instructor, results in a high
percentage of missing information due to the nature of expertise characterized by
automaticity. A CTA-based curriculum maximizes how novices learn by providing more
of the concepts, processes and principles necessary for successful task completion. CTA
accomplishes this by eliciting the underlying expert declarative and procedural
knowledge (action and decision steps) often absent in traditional curricular models. In
surgical skills education, research indicates that the knowledge required for medical
students and residents to perform complex procedures accurately and effectively is not
being fully conveyed. The long-established apprenticeship model produces well-trained
surgeons, but lacks uniformity in content development, instructional strategies and
standardized assessment to ensure expert knowledge is fully and effectively conveyed.
This study investigates the effects of CTA-based instruction to traditional instruction for
medical students and postgraduate surgical residents at a medical research university.
The performance of an Open Cricothyrotomy by fourteen participants who received
traditional expert-led instruction is compared to the performance of twelve participants
who received CTA-based instruction. Results indicate that CTA-based instruction has a
significant positive effect on procedural knowledge and performance when compared to
traditional expert-led surgical skills education. There was no difference in declarative
ix
knowledge between the groups. Limitations of the research and implications for
future CTA efforts are discussed.
1
CHAPTER 1: INTRODUCTION AND REVIEW OF THE LITERATURE
Introduction
Healthcare stakeholders are concerned about critical knowledge and technical
skill for successful surgical performance being conveyed accurately to medical students
and residents. Issues surrounding surgical skills training have prompted medical
professionals to reevaluate the mentor-based Halsteadian training method used for over a
century (Banks, Chudnoff, Karmin, Wang, & Pardanani, 2007; Halsted, 1904; Reznick &
MacRae, 2006). Increased patient safety concerns, growth in medical knowledge,
escalating complexity of procedures and higher levels of accountability (Aggarwal &
Darzi, 2006; Grantcharov & Reznick, 2008; Reznick & MacRae, 2006; Sachdeva et al.,
2007) have led the medical community to seek improvements in its current teaching,
learning and assessment methods.
Currently, mastery in surgery is highly dependent on the ability of an expert
surgical instructor to transfer necessary knowledge to novice resident learners. Research
indicates that because of automaticity, these experts can omit a significant proportion of
knowledge when they teach using current mentor-based curricular models (Clark & Elen,
2006; Feldon & Clark, 2006). Cognitive Task Analysis (CTA) is one method for eliciting
knowledge from experts that can inform more comprehensive instructional support
materials. The advantages of CTA interview techniques include drawing out all the
major steps, tasks and decisions experts employ for effective performance and enabling
novices to process more successfully and organize the actions and decision steps of a
surgical procedure (Clark, Feldon, Van Merrienboer, Yates, & Early, 2007). This study
2
will investigate if training materials informed by CTA is a viable strategy for
improving instruction and student performance in a surgical skills course. Since
instructional delivery techniques and supporting learning materials make a difference in
how people learn, the course structure will follow a Guided Experiential Learning (GEL)
model (Clark, 2004). GEL maximizes how participants process information and lends
itself well to instructional design and materials developed from CTA.
Statement of the Problem
The necessary knowledge required for medical students and residents to perform
technical surgical skills competently is not being fully conveyed in current surgical skills
training. Research indicates that expert surgeons typically omit up to seventy percent of
the information about critical actions and decisions they make when training novices;
they largely are unable to report how they solve problems or perform tasks (Clark et al.,
2007) Instruction relies on a faculty surgeon’s ability to identify and explain the essential
sequence of actions and decisions that are made during a procedure (Clark et al., 2007;
Sullivan et al., 2007). Competent surgeons are able to demonstrate how to perform a
procedure, but often are unable to articulate fully the declarative and procedural
components of a complex task. This occurs because these individuals have extensive
practice and perform tasks automatically without the need for conscious guidance or
monitoring. They solve problems and carry out tasks within their specialty areas much
faster than novices because their expertise is largely automated, allowing them to bypass
limits on conscious processing (Chi, Glaser, & Farr, 1988; Wheatley & Wegner, 2001).
3
In surgical skills education, there is no guarantee that a surgical trainer will teach
all the critical steps and decision points of a surgery to a resident because of automaticity.
Cognitive Task Analysis
Cognitive Task Analysis (CTA) is a promising strategy for improving surgical
skills instruction by capturing more of the critical information novices require to perform
a complex task than is typically gleaned from other instructional methods (Clark et al.,
2007). CTA goes beyond traditional behavioral-based curriculum development and
provides a systematic approach for obtaining, from multiple experts, accurate and
complete expert knowledge and cognitive skills required to perform a complex task.
Through a series of interviews with multiple subject matter experts, followed by the
analysis and synthesis of different expert versions of a task, the most essential knowledge
is captured in a simple and effective document called a “Gold Standard” (Clark, Pugh,
Yates, & Sullivan, 2008) that is incorporated into surgical skills instruction.
Purpose of the Study
The goal of this study is to determine if CTA-designed instruction is more
effective than the traditional instructional methods currently used to teach Open
Cricothyrotomy to surgical residents and students. Effectiveness is defined as “producing
a decided, decisive, or desired effect” ("Effective," 2009). The desired effect in this
study is a significant difference in demonstrated learning and performance outcomes
between the control and experimental groups. The objective is to see if the experimental
group demonstrates greater technical competence and makes better decisions than the
4
control group, so they are more likely to make better surgical decisions at critical
decision points and make fewer serious mistakes that cause harm to a patient.
Research Questions and Hypotheses
The research questions that will be examined in the study are:
1. Do participants in the experimental group demonstrate greater declarative
knowledge of Open Cricothyrotomy than participants in the control group?
2. Do participants in the experimental group perform the procedural action and
decision steps of Open Cricothyrotomy more accurately and completely than
participants in the control group?
The hypotheses of the study are:
H1 Participants in the CTA-based instruction group will demonstrate greater
declarative knowledge of a procedure on a post-test measure than participants
taught by traditional methods.
H2 Participants in the CTA-based instruction group will demonstrate more procedural
knowledge on a post-test measure than participants taught by traditional methods.
5
REVIEW OF THE LITERATURE
The purpose of this section is to review the relevant literature regarding current
surgical training and assessment methods, the development and functioning of expert
knowledge, curricular models that support the learning of surgery and other forms of
expertise, and the use of CTA to improve instructional outcomes.
Current Surgical Training and Assessment Methods
Apprenticeship Model
For more than a century, surgical training in the United States has followed a
Halstedian surgeon-to-resident “see one, do one, teach one” apprenticeship model (Banks
et al., 2007; Halsted, 1904; Reznick & MacRae, 2006). While this approach continues to
be the primary method for teaching surgical skills, it is vague, unstructured and based on
available opportunity rather than structured educational objectives (Grantcharov &
Reznick, 2008; Hamdorf & Hall, 2000). A resident’s acquisition of surgical knowledge
is largely determined by the medical problems available while caring for patients under a
faculty mentor in a teaching hospital (Sachdeva et al., 2007). Few standardized and
systematic instructional strategies are employed by surgical experts to ensure residents
are exposed to all cases, complications and procedures during training, resulting in wide
variation of instruction (Sachdeva et al., 2007).
The adequacy of the apprenticeship model has been increasingly questioned over
the past two decades, prompting research and recommendations for instructional
improvement to surgical skills training in residency programs (Aggarwal & Darzi, 2006;
Dunnington & DaRosa, 1994; Reznick & MacRae, 2006). The Halstedian model has
6
produced well-trained surgeons successfully for many years, so no claim is made
that it is entirely ineffective. However, there is concern about the little uniformity across
training programs and the few guarantees that residents will acquire sufficient technical
proficiency and knowledge before independently working with patients (Grantcharov &
Reznick, 2008). Change is necessary due to escalating complexity in medical
procedures, exponential growth of medical knowledge, increased concerns for
accountability, and ethics regarding student “practicing” on patients while learning
(Aggarwal & Darzi, 2006; Grantcharov & Reznick, 2008; Reznick & MacRae, 2006;
Sachdeva et al., 2007).
Standardized Curriculum
Over the past ten years, the response to this problem has been to implement
structured curricula to ensure every resident is exposed to core surgical skills. The
American Board of Surgery (ABS) and the Residency Review Committee for Surgery
(RRC-S) are the key organizations that define curriculum content, but the guidelines are
broad and do not explicitly address learning outcomes (Sachdeva et al., 2007). The
American College of Surgeons and the Association of Program Directors in Surgery
formed a Surgical Skills Curriculum Task Force to establish a National Skills Curriculum
that has been in the process of a phased implementation since 2007. The curriculum is
carefully structured and designed by content experts to enhance training through
reproducible simulations and includes assessments to verify proficiency before residents
are allowed to operate on patients (Sachdeva et al., 2007; Scott & Dunnington, 2008).
7
A key aspect of this approach is to require residents to meet standards on
simulated modules at surgical skills centers before performing the procedure on a patient.
With simulated instruction, the resident observes expert performance and then
participates in guided practice on a simulator (i.e. inanimate model) until performance
meets standards. Residents are then assessed by faculty members for operating room
readiness (Bell, 2007; Scott & Dunnington, 2008).
Banks et al. (2007) conducted a study to assess whether such surgical skills
laboratories improve resident knowledge and operative performance. For instruction on
laparoscopic tubal ligation, 20 first-year residents were assigned randomly to either a
surgical simulator laboratory paired with apprenticeship teaching, or to traditional
apprenticeship teaching alone. Basic knowledge was assessed using pre and post-tests.
Attending physicians, who were blinded to the randomization, evaluated the residents’
performance using three validating tools: a task-specific checklist, a global rating scale,
and a pass/fail grade. The residents who were assigned to the surgical simulator
laboratory performed significantly better than the control group on all three-assessment
instruments (Banks et al., 2007).
While great improvements have been made in curricular standardization, surgical
skills curriculum is developed using behavioral task analysis and focuses on training
behavioral tasks (DaRosa & Bell,2004). This does not address the critical cognitive
processes that underpin surgical decision-making (Weinger & Slagle, 2002). Since a
skillfully performed operation is seventy-five percent decision-making (Spencer, 1978), it
8
is essential for more complicated cognitive skills (such as decision-making) to
be included in the standardized curriculum.
Performance Assessment
With the move to more standardized curricular models, methods of assessment
must also be consistent across programs to ensure surgical skills competencies are met.
In their review of current practices in objective assessment of technical surgical skills,
Moorthy, Munz, Sarker and Darzi (2003) found that most surgical skills assessments are
subjective and unreliable; they argue that commonly used assessments such as
examinations, log books, and non-criteria
based direct observation of procedures are only
indicative of the procedures residents have performed with no reflection on skill or
ability. Scott et al. (2000) revealed that even the standardized American Board
of
Surgery In-Training Exam (ABSITE), with its focus on assessing a resident’s progress in
their knowledge of basic science and management of clinical problems related to general
surgery, does not measure surgical skill. In their study, post-graduate year 2 (PGY-2)
and post-graduate year 3 (PGY-3) surgery residents were tested on a laparoscopic
cholecystectomy using three assessment instruments: the multiple choice ABSITE, a
skills test on a laparoscopic video trainer, and an intraoperative global assessment. Study
results indicated that while the ABSITE does measure knowledge, outcomes do not
correlate with technical skill or operative performance.
Research has led to the development of some standardized assessment tools in the
hope of providing more reliable and valid measures of surgical performance. A
widespread tool for evaluating operative technical skills is the Objective Structured
9
Assessment of Technical Skill (OSATS) examination, which is a formal
assessment of technical surgical skills by an expert surgeon (Reznick, Regehr, MacRae,
Martin, & McCulloch, 1997). The assessment is conducted when residents perform
standardized surgical procedures in a surgical skills laboratory. The assessment uses
criteria outlined in a behavioral task-specific list that includes all of the important steps of
a procedure, which are identified and checked off as the resident completes each step
correctly. Also included is a global assessment score of overall performance, on which
an expert surgeon evaluates the resident using a point-value scale to rate specific aspects
of operative performance. Studies have repeatedly demonstrated the OSATS exam as a
reliable and valid approach to measuring surgical technical skill (Martin et al., 1997;
Reznick & MacRae, 2006; Reznick et al., 1997). While the OSATS is far more reliable
than methods historically used, there is room for improvement.
Instructional Variation and the Effect of Expertise
While national curricula and standardized assessment measures can offer more
consistent approaches to surgical skills education, significant variation remains in how
the knowledge necessary to perform a task is conveyed in the dynamic classroom setting
(Hamdorf & Hall, 2000; Sullivan et al., 2008; Velmahos et al., 2004). A significant
cause of instructional variation is the expert who may teach differently to diverse levels
of learners, underestimate learning difficulties faced by novices, or oversimplify tasks as
their own automated knowledge of a procedure makes details less apparent (Hinds, 1999;
Sullivan et al., 2008). Experts have a high level of conceptual abstraction, solve problems
deductively, have superior working memory and apply automated procedures without
10
conscious thought, known as automaticity (Feldon, 2007). Expert performance
is a product of experience-based knowledge that can be recalled quickly and consistently
and then deployed (Chase, 1972; Feldon, 2007). Experts are capable of a variety of
advanced skills that novices lack due to limitations on conscious processing (Clark &
Estes, 1996; Miller, 1956). Evidence indicates that experts may have more direct access
than novices to much of their declarative knowledge within their domain experience
(Baddeley, 1997), and possess highly efficient domain-specific rules to problem-solve
under particular conditions (Means & Gott, 1988).
Some researchers suggest that expertise requires a minimum of ten years of
“deliberate practice,” or effort, to optimize performance and make original contributions
within an area of expertise (Ericsson, Krampe, & Tesch-Römer, 1993). More recently,
Anderson (2002) provides evidence that significant changes in automated and effective
performance can be achieved in at least 100 hours of practice. Since the development of
expertise relies on improvement of individual task components, complex tasks must be
deconstructed into very small learning pieces to accomplish this (Lee & Anderson, 2001).
Unfortunately, educators are not always able to convey information to novices in
its smallest components because of the nature of expertise. Automaticity, which is
considered a hallmark of expertise, frees up limited cognitive processing resources to
accommodate additional cognitive demands that arise while performing a task (Feldon,
2007). However, the negative impact on instruction is that automated knowledge may be
omitted from procedural explanations. Several studies reveal that when experts describe
how they perform a procedure (self-report), they unintentionally misrepresent the
11
conceptual knowledge on which they base their performance (Clark et al.,
2007). They can omit up to seventy percent of critical actions and decision steps when
training novices, resulting in instructional content that is inaccurate or incomplete (Clark
& Elen, 2006; Feldon & Clark, 2006).
Types of Knowledge
The process of teaching, learning and assessing surgical skills requires the
transmission of information from the expert instructor to the novice student. The key to a
mastery learning experience is the acquisition of the critical components of knowledge:
declarative (what it is), procedural (how to do it) and the conditions under which to
perform a procedural task.
Declarative Knowledge
Declarative knowledge is acquired information and factual knowledge (Anderson,
1976) of which a person is consciously aware and can describe, including concepts,
processes and principles (Clark & Estes, 1996). Tasks that individuals perform are first
encoded as declarative knowledge (what things are and how they work) and often
become schemas used to understand entire processes, or conditions linked to rough sets
of procedural steps that are used to solve problems and accomplish goals (Maupin, 2003).
The conscious quality of declarative knowledge and the speed at which it can be acquired
and modified supports novel problem-solving and the generation of procedures to handle
these situations when they occur frequently (Clark & Estes, 1996). When teaching new
procedures and tasks to novices such as medical students and surgical residents, it is
appropriate to focus on required declarative knowledge so they are able to understand the
12
steps needed to complete the procedure. The declarative knowledge may
contain decision points and responses to frequently encountered problems during a
surgical procedure.
Procedural Knowledge
Procedural knowledge is how to do things. Most procedural knowledge is
implicit and cannot consciously be recalled or explained. It is developed through active
application of procedural routines in settings where corrective feedback is available.
Over time, procedural routines become stable components of a task and no longer require
conscious thought. This is why experts may not be able to describe all the “mental” steps
in a procedure, as they have become automated and are no longer accessible to conscious
processes (Clark & Estes, 1996). While experts may believe they know how they
perform tasks, significant portions of their conscious awareness of their automated
problem-solving strategies are inaccurate (Clark & Estes, 1996).
Procedural knowledge includes conditional knowledge, which is information
about when to respond under different circumstances. Conditional knowledge helps
people make decisions about when to employ a skill. For example, a resident may learn
what a skill is and how to perform it, but may not learn precisely when (or when not) to
apply it during a procedure.
Cognitive Task Analysis
The goal of cognitive task analysis (CTA) is to elicit the conscious and non-
conscious (automated) knowledge from experts in order to expose all the critical action
and decision-making steps necessary to perform a task or solve a problem. CTA is an
13
interview and observation method that captures the knowledge, goals,
strategies, and decisions that underlie observable task performance (Clark et al., 2007). It
provides a systematic approach to capturing expert knowledge of a specific task from
multiple experts that informs instructional design by revealing the knowledge and skills
that must be taught to achieve performance goals (Clark et al., 2007). Regardless of the
training domain, performance improvement is the ultimate goal and reason to conduct a
CTA.
Most training systems in use today are developed based on behavioral
psychology, in which analyses of tasks and jobs focus on observable behaviors and
ignore cognitive processes and structures (Clark & Estes, 1996). As jobs require more
complicated problem-solving skills, a behavioral approach no longer meets the training
needs of most organizations. Research indicates that CTA-supported training is suited
better for the complex tasks and problem-solving skills required in current work
environments (Clark & Estes, 1996). Advances in the understanding of cognitive
processes and structures facilitate accurate and effective training developed through
advanced task analyses, such as CTA, rather than through behavioral approaches (Clark
& Estes, 1996). The methods for conducting CTAs continue to evolve with advances in
cognitive science and training (Clark & Estes, 1996; Clark et al., 2007).
The Concepts, Processes and Principles Protocol
The theoretical framework informing this study is Concepts, Processes &
Principles (CPP). CPP is a technique for organizing expert knowledge into a sequence of
tasks and subtasks based on concepts, processes and principles (Clark, Yates, Early &
14
Moulton, 2010). Using the CPP method, the CTA interviewer asks the expert to
define any domain specific concepts, such as terminology, and to provide examples. The
expert is asked to describe processes, such as step-by-step tasks or the operation of
equipment. The goal is to elicit the cause and effect relationships, or principles that
govern a given domain, in order to elucidate what causes problems and determine how to
modify solution strategies based on principles and various conditions. The information
for the CPP protocol is reported in terms of an overall goal, conditions defined by
indications and contra indications, necessary equipment, tasks, and steps required for
each task, listed in the order in which they should be completed. Conditional (if/then)
statements applicable to decision-making are also be included under each step, as needed.
Multiple subject matter experts are interviewed using this method and their
responses are verified by domain experts to reach a consensus on a “gold standard”
representing the most effective and efficient way to solve a specific problem (Clark et al.,
2007). Chao and Salvendy (1994) found that knowledge elicited from at least three
subject matter experts to describe a procedural task greatly improves the validity and
completeness of acquired information by as much as forty percent. They found that the
self-reported knowledge of a single expert is not as accurate as the collective knowledge
of several experts; a single expert may not have experienced all the nuances of a
procedure nor had opportunities to develop responses to a variety of complications (Chao
& Salvendy, 1994). This elucidates a key reason that CTA using the CPP method is
effective: by interviewing multiple experts, it captures a greater percentage of the
declarative and procedural knowledge than can be captured from one expert alone. When
15
applied to a standardized curriculum, it can help ensure that novices are
exposed to all of the knowledge necessary to perform a procedure accurately and
successfully.
Instructional Design Informed by CTA
Once expert knowledge is elicited, training materials are developed using a
Guided Experiential Learning (GEL) course model. GEL maximizes how learners
process information and lends itself well to instructional design and materials developed
from CTA. The GEL course design is informed by Merrill’s (2002a) “First Principles of
Instruction” which captures the most effective components of instruction supported by
solid research on the learning benefits of various training methods (Clark, 2004).
Merrill’s (2002a) principles state that learning is promoted when all students receive: 1)
realistic field-based problems to solve; 2) analogies and examples that relate trainees’
relevant prior knowledge to new learning; 3) clear and complete demonstrations of how
to perform key tasks and solve authentic problems; 4) frequent opportunities to practice
during training (to apply what is being learned by performing tasks and solving
problems) while receiving corrective feedback; and 5) application practice that includes
“part task” (practicing small chunks of larger tasks) and “whole tasks” (applying as much
as possible of what is learned to solve complex problems that represent challenges
encountered in operational environments).
To support these instructional principles, the GEL model requires trainers to
sequentially provide learners with: 1) Objectives for the task by specifying actions,
conditions and standards that must be achieved; 2) Reasons for learning the task which
16
include advantages of learning and risks of failure to learn and transfer; 3) An
overview which provides knowledge models and content outline; 4) Conceptual
Knowledge which includes the concepts, processes and principles necessary to learn to
perform a task or solve a problem with examples and analogies that support learning; 5)
A demonstration of the procedure with clear “how to” descriptions for all elements of a
task or solution; 6) Part- and whole-task practice of procedures with corrective feedback;
7) Challenging, competency-based tests (Clark, 2004).
Evidence of CTA Effectiveness Outside of Medicine
When students have accurate learning tools, their learning curve increases. CTA
improves the accuracy of learning tools by allowing access to the cognitive automated
decisions made by experts and deconstructing automated procedures into concrete and
understandable steps (Clark et al., 2007). In a study comparing instruction for teaching
spreadsheet skills, results indicated that CTA-supported instruction led to greatly
improved task performance (Merrill, 2002b). In the study, one group received no training
(discovery- learning) while the other received training that emphasized Merrill’s
principles and incorporated a GEL course informed by CTA techniques (Clark, 2004). In
a problem-solving task where participants had to solve three real-world spreadsheet tasks,
learners in the CTA-based group scored 89% compared to 34% for the discovery-learning
group (Merrill, 2002b). In addition to outperforming the discovery-learning group, the
CTA-based group also required less time to complete the task, 29 minutes compared to
more than 60 minutes (Merrill, 2002b).
17
Schaafstal, Schraagen and Berlo (2000) developed CTA-based training
for naval weapons engineers to help improve trouble shooting performance and
maintenance of communication, weapons and sensor systems. After conducting a CTA
to highlight the knowledge, skills, tasks and cognitive processes involved, the researchers
found performance shortfalls were due to novice technicians not learning the processes to
properly operate the equipment and to approach problem-solving in a goal directed
manner. A supplemental one-week CTA-based training course was given to 11
participants who had taken an existing six-week course. They were then tested along
with 21 technicians who only completed the existing course. While the CTA
experimental group did not score significantly higher than the control group on the
knowledge test, the experimental group did score much higher on all other measures in
trouble shooting scenarios. Thereafter, when the CTA-based course and similar
evaluation was used alone to train several groups of corporals, it resulted in significantly
higher performance scores than those of participants in the original six-week course: the
corporals were able to solve 95 percent of the problems and scored significantly higher
on reasoning and system knowledge.
Evidence of CTA Effectiveness in Medicine
Medical curricular models based on experts’ cognitive processes, as are elicited
and adapted through CTA, are substantially more effective than traditional apprenticeship
or didactic lecture training methods (Clark et al., 2007). Crandall and Getchell-Reiter
(1993) demonstrated this in their study of undocumented components of nursing
expertise in a neonatal intensive care setting. Using a technique like CTA, which they
18
call Critical Decision Making (CDM), the researchers organized knowledge
about Early Sepsis Assessment gleaned from interviews with expert nurses and
developed it into a standardized guide that outlined assessment cues, sepsis indicators and
incident accounts. The results revealed that some sepsis indicators used by experienced
nurses were not identified in the research or training literature. Regarding the guide that
was developed and implemented, 46 percent of nurses said they gained new knowledge
from the guide, and all stated they would have benefitted from it when they were less
experienced. Furthermore, managing nurses indicated they would use the guide as an
instructional tool for novice nurses.
Clark et al. (2008) found that surgeons who report a description of events,
decision-making strategies and problem-solving tactics used in emergency surgical
situations omitted 68.5% of the procedural steps when compared to a standard created
from a CTA protocol. Similar findings were revealed by Sullivan et al. (2008), in which
subject matter experts were instructed to think out loud and be as thorough as possible
when describing steps and action points to second-year residents during colonoscopy
surgical training. After the procedure, the experts participated in a free recall to describe
the procedure in detail and discuss if they believed they had given a complete description
of the task to the residents. The study found that the experts omitted at least 50% of the
essential “how to” steps and 57% of the critical decisions regarding when to perform
certain steps, compared to a CTA-based standard of the colonoscopy procedure.
Maupin (2003) and Velmahos et al. (2004) examined CTA-based instruction compared to
traditional instruction using behavioral task analysis in a central venous catheter (CVC)
19
course for surgical interns. Using the CPP model, two expert surgeons were
interviewed to elicit the knowledge required to perform the procedure. The information
was used to develop a CVC lesson and training support documents that were deployed in
the course using an experimental design. Both the experimental group (n=12) and control
group (n=15) completed a 15-item multiple choice pre-test to determine baseline
knowledge of the CVC procedure. The control group learned the CVC procedure with
the traditional “see one, do one, teach one” mentor model, while the experimental group
received the CTA-based training. The CTA training included a three-hour lesson and
practice on an inanimate model. Using the 15-item multiple-choice assessment used for
the pre-test and a 14-point standardized checklist used to evaluate the interns while
performing the procedure on patients, both groups of interns were evaluated within ten
weeks of the instruction session. The experimental group scored significantly higher than
the control group on the 15-item multiple-choice test, with mean scores of 11 and 8.64,
respectively. The experimental group also performed significantly better on the
procedural checklist, with a mean score of 12.6 out of 14 compared to the control group’s
mean score of 7.5. Overall, the study found that interns who learned from CTA-based
instruction made better surgical decisions, were more confident, exhibited improved
transfer, were quicker in performing the procedure and had fewer important errors than
interns who learned from traditional instructional methods (Maupin, 2003; Velmahos et
al., 2004).
Sullivan et al. (2007) demonstrated the effectiveness of CTA-based instruction to
teach the skills and strategies necessary for percutaneous tracheostomy (PT) placement.
20
A PT curriculum was developed from interviews with three experts that
described the step-by-step tasks and cognitive decision points to perform the procedure.
Postgraduate year (PGY) 2, 3, and 4 surgical residents were randomly assigned to either
an experimental group (n=9) or a control group (n=11). The experimental group received
instruction from curricular materials developed from the CTA and a demonstration on an
inanimate model. The control group received the traditional curriculum for PT placement,
a lecture and demonstration on the same model. Technical competence in performing a
PT and knowledge of cognitive decisions made during the procedure were assessed one
month and six months after instruction. Technical competence was assessed using a 25-
item objective checklist representing the important steps necessary to complete the
procedure. To assess cognitive decisions made during the procedure, each resident
performed a videotaped think-aloud assessment that used a 40-point assessment tool to
measure the cognitive decisions made during the procedure. The CTA experimental
group had significantly higher scores than the control group on both assessments one
month and six months after instruction. This study strengthens the findings regarding
CTA-based instruction and long-term knowledge retention based on the study design that
reassessed residents six months after instruction, going beyond other CTA studies that
reassessed residents within a few weeks of instruction.
Clark et al. (2008) tested CTA as a novel approach to medical after action reviews
(AAR), in which trauma surgeons report a description of events, goals, decision-making
and problem-solving strategies used in an emergency shunt procedure to temporarily
restore blood to the femoral artery. Nine trauma surgeons were interviewed to elicit an
21
unaided description of the procedure (a no-CTA condition). A tenth trauma
surgeon was interviewed using CTA methods. A protocol of each surgeon’s description
was developed and aggregated into a final gold standard. Surgeons’ protocols were then
compared to the gold standard to assess the accuracy and completeness of each surgeon’s
descriptions. Without CTA, surgeons omitted 68.75% of the standard procedural steps
when compared to a CTA-based gold standard.
Conclusion
A review of the literature provides strong evidence that a CTA-based curriculum
is effective for novices and can expose them to the critical knowledge necessary to
perform a task or solve a problem. In medical education, research indicates that the
current apprenticeship model provides experience, but lacks a uniform approach to
instruction and assessment to ensure vital expert knowledge is conveyed. Additionally,
findings reveal that the traditional lecture model that places the expert in the role of
instructor results in a high percentage of missing information due to the nature of
expertise, characterized by automaticity. While experts have a variety of advanced skills,
they often omit essential declarative and procedural knowledge necessary for novices to
complete a task effectively and accurately. A growing body of research indicates that
instructional materials developed using CTA, as opposed to those based on behavioral
objectives, can fill this persistent gap.
This Study
This study compares the results of an Open Cricothyrotomy surgical procedure
performed by an experimental group that receives CTA-based instruction to the results of
22
a control group that receives traditional instruction on the Open
Cricothyrotomy procedure. The purpose is to determine if expert instruction
supplemented by CTA-based training materials is more effective than the behavior-based,
expert-led lecture, demonstration and practice model currently used in surgical skills
laboratories. The research questions examined are:
1. Do participants in the experimental group demonstrate greater declarative
knowledge of Open Cricothyrotomy than participants in the control group?
2. Do participants in the experimental group perform the procedural action and
decision steps of Open Cricothyrotomy more accurately and completely than
participants in the control group?
23
CHAPTER 2: METHOD
This chapter outlines the research methodology used in this study. It describes the
study design, surgical procedure selected, study participants and sampling procedure. It
provides details about the CTA knowledge elicitation process, the development of
curricular materials and assessments, and the expert instructors participating in the study.
Lastly, the chapter explains the study procedure and data analysis plan.
Study Design
This study compares the results of an Open Cricothyrotomy surgical procedure
performed by an experimental group that received CTA-based instruction to the results of
a control group that received traditional instruction on the procedure. The independent
variable was the type of instruction, either a CTA supported module or an existing
behavior-based instructional module. The CTA module included a script for the expert
instructor, which accompanied a PowerPoint presentation and a student job-aid on the
Open Cricothyrotomy procedure. The lecture format, guided practice and evaluation
procedures were the same for both groups. Participant baseline declarative knowledge of
the procedure was measured using a six-question (17 possible points) pre-test. The
dependent variable was participant performance on two post-test instruments – a written
14-question post-test and a surgical skills checklist used to evaluate the participant as he
or she performed the procedure on an inanimate model. It was anticipated that CTA-
based instruction would be more effective in providing the declarative knowledge and
critical procedural steps required to complete the Open Cricothyrotomy than the currently
employed lecture and practice model.
24
The surgical task. An Open Cricothyrotomy is a procedure to secure a
patient's airway during certain emergency situations. It is one of the quickest and safest
ways to relieve upper airway obstruction when simpler, less-invasive techniques have
failed or are not feasible. It entails incising the cricothyroid membrane and inserting a
tracheostomy tube directly into the trachea to establish a definitive airway (Roberts,
Hedges, & Chanmugam, 2004). Open Cricothyrotomy involves procedural steps, which,
if performed inaccurately, can result in unnecessary risk and complications for the
patient.
Participants and Recruitment
Thirty-three medical students and surgical residents from a university medical
school voluntarily participated in the study. After Institutional Review Board approval,
medical students and residents were recruited using a flyer or by verbal invitation during
regularly scheduled training sessions/classes. Each participant filled out a Demographic
Information Survey (Appendix A) and received an information sheet outlining the study.
Participants were not asked to share any personal information, and any personal data
obtained was not linked to the information gathered during the study. Data linked the
participant to their assigned group only (control or experimental).
Sampling procedure. This study followed a stratified random sampling. The
director of the medical school’s surgical skills education center divided participants by
education level: third-year medical students, second-year postgraduate residents and
third-year post graduate residents. Random sampling was applied by the study’s two
investigators to create an experimental and control group from these categories.
25
CTA Procedure
The CTA for the Open Cricothyrotomy procedure was conducted in five phases as
outlined by Clark et al. (2010): (1) Identification of tasks and collection of preliminary
knowledge; (2) Identification of required knowledge to perform the tasks and subtasks;
(3) Elicitation of the required knowledge from multiple SMEs; (4) Analysis and
verification of data collected; (5) Formatting of results for the intended application.
CTA-based materials for this study were developed using this five-phased approach as
follows:
1. Preliminary research on Open Cricothyrotomy surgical procedure was conducted
by examining medical books and scholarly resources.
2. A preliminary list of knowledge types used to perform an Open Cricothyrotomy
was generated from Phase 1 findings to assist in organizing the information
elicited from the surgeons.
3. Semi-structured interviews were conducted with six expert trauma surgeons at the
university’s medical center to identify the cognitive elements and sequence of
tasks necessary to conduct an Open Cricothyrotomy. All six surgeons are
instructors at the university hospital and were interviewed separately. At each
interview, one to three investigators participated in asking interview questions.
During the interview, surgeons responded to a series of open-ended questions
designed to elicit the overall goal of the procedure, necessary equipment, major
action steps, indications and contra-indications, conditions for decision steps and
standards to perform an Open Cricothyrotomy successfully. Questions were also
26
asked to elicit any new concepts medical students or residents may not
know and to reveal typical problem areas novices may encounter when
performing the procedure. The interviews were recorded with note-taking and
digital audio recorders.
4. The digitally recorded interviews were transcribed and coded following the CPP
protocol to create a CTA report. Two to three raters coded each transcript by
reviewing each line to identify and tally the declarative and procedural
knowledge, including action and decision steps. The inter-rater reliability for all
three transcripts was 96%. Each rater also created a flowchart for each transcript
to compare and verify the action steps and decision points. Once consensus was
reached, a CTA report was developed for each expert based on the content from
his or her own interview transcript. The CTA report identified the goal of the
procedure and sequenced all major steps and sub steps. It identified the
indications and contra-indications, decision steps associated with specific
conditions, necessary equipment, procedural standards, and included concepts that
novices may not know and typical problem areas for learners.
5. Each expert surgeon reviewed and verified the CTA protocol and flowchart
documents that were based on their own interview for accuracy and completeness.
They were asked to track changes if providing corrections or additional
comments. The corrected protocols were aggregated into a single master draft
CTA report. All six surgeons were asked to review the master draft and provide
corrections/additions. Five surgeons reviewed the master draft; one surgeon did
27
not respond prior to the study date. The document was updated based
on the five experts responses and became the “Gold Standard” that served as the
master protocol to inform the development of the CTA-supported Open
Cricothyrotomy lesson (Appendix B).
Development of curricular materials and assessments. The development of
training materials, a pre-test, a post-test and an Open Cricothyrotomy surgical skills
checklist were informed by the gold standard CTA report. Training materials were
developed using the Guided Experiential Learning (GEL) model (Clark, 2004). The
curricular materials for the instructor included a detailed script (Appendix C) and a
PowerPoint presentation to use while teaching the CTA-based course. Both followed the
sequence and content from the CTA gold standard report. Materials for the participants
included a copy of the instructor’s PowerPoint and an Open Cricothyrotomy job-aid
(Appendix D) that outlined the Open Cricothyrotomy procedure in the fashion of a CTA
protocol report. The surgeon teaching the CTA-based course participated in the
curriculum development process by reviewing and commenting on all course materials.
In addition, a PGY 3 surgical resident who did not participate in the study reviewed the
CTA-based materials for comprehension.
To determine baseline declarative knowledge, a six-question (17 possible points)
pre-test was developed (Appendix E). The points for the pre-test were based on all
possible expert answers for each question. To assess the acquisition of procedural action
step knowledge, a 19-point Open Cricothyrotomy skills checklist (Appendix F) was
created. The checklist consisted of three columns. The first outlined the major steps
28
necessary to perform an Open Cricothyrotomy. The second was subdivided
into three possible choices the raters could select as the participant performed each step:
“Not Done,” “Incorrect” or “Done Correctly.” The third column on the checklist was a
comments field for raters to make notes about the medical student’s or resident’s
performance on each task. To ascertain declarative and procedural decision step
knowledge, a fourteen-question (37 point) post-test was developed (Appendix G). The
points for the post-test were based on all possible expert answers for each question with
30 possible points for declarative knowledge and seven possible points for decision steps.
To ensure internal validity, the control and experimental groups were subdivided
without the participants’ knowledge. The subgroups were administered parallel forms of
the assessment instruments, either Version 1or Version 2. Depending on the version, the
instrument was prefaced with one of two emergency medical scenarios (indications and
contra-indications for the procedure) for participants to consider while completing the
assessment.
The surgical skills checklist items were the same for all participants, but the
scenario given (conditions and contra-indications) was different depending on the version
received (Version 1 or 2). Regardless of version, the first four questions of the pre-test
were identical for all groups and the first nine questions of the post-test were identical for
all groups. The remainder of the tests were different depending on version, each crafted
as an equivalent measure. Thus the remainder of pre-test Version 1 and post-test Version
1 had the same questions, while the remainder of the pre-test Version 2 and post-test
Version 2 had the same questions.
29
For each participant, the pre-test and the checklist they received had the
same medical scenario while the post-test had the alternate scenario to test knowledge
application. If a participant received pre-test Version 1, he/she was assessed using
Checklist Scenario 1 and took the post-test Version 2. If a participant received pre-test
Version 2, they were assessed with the Checklist Scenario 2 and took the post-test
Version 1 (see Table 1).
Table 1: Distribution of Assessment Instruments
Experimental Group (A) Pre-test Checklist Post-test
7 participants:
Version 1
Scenario 1 Scenario 1
Version 2
Scenario 2
5 participants:
Version 2
Scenario 2 Scenario 2
Version 1
Scenario 1
Control Group (B) Pre-test Checklist Post-test
16 participants:
Version 1
Scenario 1 Scenario 1
Version 2
Scenario 2
5 participants:
Version 2
Scenario 2 Scenario 2
Version 1
Scenario 1
Expert instructors. The instructor for the control group and the instructor for
experimental group each had similar experience in the classroom and with teaching Open
Cricothyrotomy. The control group instructor had more years of experience as a surgeon.
They were both second year trauma critical care fellows. They both had received
outstanding teaching evaluations that were equivalent. The control group instructor used
existing curricular materials that she had developed. The instructor teaching the
experimental group was provided the CTA-based instructional materials and asked not to
deviate from these materials in order to maintain the validity of the CTA-based
curriculum.
30
The Study Procedure
The day before the study, participants who had confirmed their participation were
categorized by education level and then randomly divided into the control and
experimental groups. Participants who arrived without confirmation on the day of the
study were randomly divided onsite. On the day of the study before the participants
arrived, two expert surgeon instructors and three expert surgeons who were assisting with
the study were briefed on the study procedures. This included their responsibilities in
assisting with the guided practice and evaluating students using the surgical skills
checklist.
The study was conducted over a three-hour period. Upon arrival at the study, each
participant in the control group (N=21) and the experimental group (N=12) were given an
envelope that included the pre-test clipped to the exterior and a checklist and post-test on
the interior. Participants completed the 6-question pre-test to assess baseline declarative
knowledge of Open Cricothyrotomy (Appendix E) and submitted it to one of the two
study investigators.
A study investigator provided a short introduction of the purpose of the study to
all participants in the Surgical Skills Center classroom. The control group then moved to
another classroom to observe a 30-minute lesson on Open Cricothyrotomy using existing
curricular materials and course structure, which included a lecture accompanied by a
PowerPoint presentation and observation of a demonstration. The experimental group
remained in the Surgical Skills Center and observed a 30-minute lesson on Open
Cricothyrotomy supported by CTA, which included an instructor script to accompany a
31
PowerPoint and a student job aid (Appendix D) that outlined the Open
Cricothyrotomy procedure in the fashion of a CTA protocol report.
Immediately following the instructional sessions, both participated in a 30-minute
guided practice session. During the session, participants remained with their assigned
group (control or experimental). There were five practice stations, two for the
experimental group and three for the control group. One expert surgeon was at each
station to guide students during the practice session. The experimental group was to use
the Open Cricothyrotomy job aid to assist in the practice session (Appendix C). While
each participant practiced, they verbalized their actions and decisions as they proceeded.
All participants who practiced received immediate verbal guided feedback from the
attending surgeon. Seven participants in the control group were unable to practice
because of time constraints. After the guided practice session, participants were asked to
convene with their group (either control or experimental) away from the practice stations.
Each participant was then individually evaluated as they performed an Open
Cricothyrotomy on the inanimate model. The attending surgeon at the station assessed
the acquisition of procedural knowledge (action steps) using a 17-step (19 possible
points) surgical skills checklist (Appendix F). After the checklist evaluation, the
participants took a 14 question (37 possible points) post-test (Appendix G). Once the
post-test was complete and all materials were collected, the control group participants
were given the opportunity to receive a copy of the CTA-based Open Cricothyrotomy
training materials.
32
Data Analysis
All data sheets were coded so that participants could only be identified by group
(control or experimental) and student number, to maintain anonymity and confidentiality.
The pre-test, post-test and surgical skills checklist were graded by two raters who reached
consensus on every item for 100% inter-rater reliability. The data was then entered into a
Microsoft Excel spreadsheet and analyzed using Statistical Package for the Social
Sciences (SPSS) 14 (Release 14.0.0).
The independent variables for the analysis were the type of instruction, either
traditional expert guided or CTA supported. The dependent variables were the
performance scores from the written post-test and procedural checklist. To answer
research question one regarding experimental group participants demonstrating greater
declarative knowledge of Open Cricothyrotomy than the control group, an independent t-
test was used to compare the effects of participation in the control or experimental group
to the participants’ total declarative knowledge score on the written post-test. To answer
research question two regarding the experimental group performing the procedural action
and decision steps of Open Cricothyrotomy more accurately and completely than
participants in the control group, an independent t-test was used to compare participation
in the control or experimental group with the participants’ total score on the procedural
checklist. To further investigate question two, an independent t-test was also used to
compare the effects of participation in the control or experimental group to the
participants’ total procedural decision step knowledge score on the written post-test. A
95% confidence level (P < 0.05) was used for all statistical analyses.
33
CHAPTER 3: RESULTS
This study compares the declarative knowledge and procedural performance of an
experimental group that received CTA-based instruction with a control group that
received traditional instruction in the Open Cricothyrotomy procedure. The goal was to
establish if an expert-led instructional module informed by cognitive task analysis (CTA)
interviews is more effective than a traditional expert-led lecture and practice instruction
model. The anticipated results were that the experimental group receiving CTA-based
instruction would demonstrate greater declarative and procedural knowledge, and
produce fewer procedural mistakes, than the control group receiving traditional
instruction on the Open Cricothyrotomy procedure at a 95% confidence level (P < 0.05).
Data were analyzed to answer the following research questions:
1. Do participants in the experimental group demonstrate greater declarative
knowledge of Open Cricothyrotomy than participants in the control group?
2. Do participants in the experimental group perform the procedural action and
decision steps of Open Cricothyrotomy more accurately and completely than
participants in the control group?
Participant Group and Pre-test Analyses
Seven participants in the study were unable to take part in the guided practice
portion of the instruction session; they were removed from the data set because they did
not complete the study and thus had incomplete/missing data. As a result, there were 26
participants in the final analysis: n=12 for the experimental group and n=14 for the
control group. The final experimental group had seven males and five females and
34
included seven third-year medical students, three second-year postgraduate
residents and two third-year postgraduate residents. The control group had nine males
and five females and included 12 third-year medical students, one second-year
postgraduate resident and one third-year postgraduate resident (see Table 2).
Table 2: Participant Distribution in Study Groups
Experimental Group (A)
3
rd
Year Med.
Students
2
nd
Year
Postgrad.
Residents
3
rd
Year
Postgrad.
Residents
7 Males: 4 3 0
5 Females: 3 0 2
Control Group (B)
9 Males: 8 1 0
5 Females: 4 0 1
To ensure there were not any negative effects on study outcomes based on group
composition, pre-test total ratio scores were analyzed using a Univariate ANOVA: Tests
of Between Subject Effects. The results revealed no significant effects on group pre-test
scores (dependent variable) between or within the experimental and control groups due to
experience F(6,19) = .414; p = .860 or gender F(6,19) = .396; p = .873 variables (see
Appendix H, Table H-1).
Pre-test Performance of Declarative Knowledge
Participants took a 6-question pre-test (17 possible points) to assess their baseline
declarative knowledge of Open Cricothyrotomy. The mean scores of the control and
experimental groups on the pre-test indicate similar baseline knowledge of the procedure.
The average score of the experimental group on the pre-test was 5.4 points (SD = 1.68)
while the average score of the control group was 5.5 points (SD = 1.83). An independent
35
samples t-test revealed no significant difference between groups on pre-test
scores: t(24) = -.120, p = .905 (see Appendix H, Table H-2).
Overall Post-test Performance
When overall post-test scores were analyzed, the mean scores of the control and
experimental groups indicated similar knowledge of the Open Cricothyrotomy procedure
after the instructional and guided practice sessions. The average score on the post-test for
the experimental group was 18.17 points (SD = 3.61) while the average score for the
control group was 16.71 points (SD = 2.64). An independent samples t-test analysis of
post-test scores revealed no significant difference between the experimental group and
the control group: t(20) = 1.15, p < .26 (see Appendix H, Table H-3 ).
Question 1: Do participants in the experimental group demonstrate greater
declarative knowledge of Open Cricothyrotomy than participants in the control group?
To investigate question 1, declarative knowledge scores from the written post-test
were analyzed to determine if there was a significant difference between groups in
declarative knowledge. The mean score of correct declarative responses on the post-test
for the experimental group was 14.5 out of 30 possible declarative knowledge points (SD
= 3.2) and the control group mean score was 13.9 (SD = 2.7). Results indicate there was
no significant difference between groups in declarative responses on the post-test (t(22) =
0.55, p = .59). These results indicate Hypothesis 1 was not supported in that participants
in the experimental group did not demonstrate greater declarative knowledge than
participants in the control group (see Appendix H, Table H-4).
36
Question 2: Do participants in the experimental group perform the
procedural action and decision steps of Open Cricothyrotomy more accurately and
completely than participants in the control group?
To answer Question 2, the procedural skills checklist was analyzed to determine if
there was a significant difference between groups in procedural performance of Open
Cricothyrotomy on an inanimate model. Instructors evaluated participants’ procedural
steps by marking “correct,” “incorrect” or “not done.” They also noted which items were
performed out of order in the notes field. The mean scores for total correct steps
performed on the 17 item procedural checklist (19 possible points) were 17.75 points (SD
= 2.34) for the experimental group and 16 points (SD = 1.88) for the control group. An
independent samples t-test revealed a significant difference between groups on the
procedural checklist performance scores: t(21) = 2.08, p = .050 (see Appendix H, Table
H-5). These results indicate Hypothesis 2 was supported; the experimental group
demonstrated more procedural knowledge (action steps) on a post-test measure than
participants taught by traditional methods.
To further answer Question 2, the written post-test was analyzed to determine if
there was a significant difference between groups in the application of procedural
decision steps. Four questions on the post-test specifically asked the learner to apply
knowledge or make a decision in order to answer the question. The mean score of correct
procedural decision step responses on the post-test for the experimental group was 3.67
out of four possible decisions (SD = .89) and the control group mean score was 2.86 (SD
= .54). An independent samples t-test revealed a significant difference between groups:
37
t(18) = 2.76, p = .013 (see Appendix H, Table H-6). These results indicate
Hypothesis 2 was supported in that residents in the experimental group did demonstrate
more procedural knowledge (decision steps) on a post-test measure than participants
taught by traditional methods.
Conclusion
Statistical analyses reveal that CTA-based instruction has a significant positive
effect on procedural knowledge and performance when compared to traditional expert-led
surgical skills education. The hypotheses that were that: 1) Participants in the CTA-based
instruction group will demonstrate greater declarative knowledge of a procedure on a
post-test measure than participants taught by traditional methods; and 2) Participants in
the CTA-based instruction group will demonstrate more procedural knowledge on a post-
test measure than participants taught by traditional methods. Results indicate that
hypothesis one was not supported; there was no effect on declarative knowledge
regardless of the type of instruction. Hypothesis two was supported in that participants in
the experimental group demonstrated more procedural action step knowledge and applied
more decision step knowledge than the control group.
38
CHAPTER 4: DISCUSSION
The outcomes of this study indicate that CTA-based instruction has a significant
effect on procedural knowledge and performance for medical students and residents
learning Open Cricothyrotomy procedure. The type of instruction (traditional expert-
guided or CTA-based) did not influence declarative knowledge. Results for each
hypothesis, study limitations, observations and suggestions for future research are
discussed in this section.
Hypothesis 1: Participants in the CTA-based instruction group will demonstrate
greater declarative knowledge of a procedure on a post-test measure than participants
taught by traditional methods.
There was no statistical significance between groups on the questions on the post-
test assessment that measured declarative knowledge. Hypothesis 1 was not supported;
participants in the CTA-based instruction group did not demonstrate greater declarative
knowledge of a procedure on a post-test measure than participants taught by traditional
methods. A key goal of CTA is to uncover all of the declarative knowledge necessary to
perform a procedure more effectively and accurately. This study, however, did not
compare the amount of declarative knowledge in each group’s curricular content. Even if
the amount of declarative knowledge was equal in both groups in the study, it was
anticipated that Merrill’s (2002a) training principles and the GEL model would support
learning better than the traditional learning model. It is feasible that the design of the
study and of the written post-test instrument may have produced no difference between
39
groups for declarative knowledge. A sizeable amount of the post-test was on
declarative knowledge (15 open-ended questions). Participants appeared eager to leave
by the end of a three-hour session, and they may have been unwilling to completely and
accurately fill out the lengthy post-test administered at the end of the session. Review of
the completed tests revealed that many answers appeared cursory and incomplete. To
improve future studies, it is recommended that investigators thoroughly consider the
possible effects of assessment length and the timing of administering the assessment.
Hypothesis 2: Participants in the CTA-based instruction group will demonstrate
more procedural knowledge on a post-test measure than participants taught by
traditional methods.
There was a significant difference in procedural action step knowledge on the
surgical skills checklist. Hypothesis 2 was supported; participants in the CTA-based
instruction group demonstrated more procedural knowledge on a post-test measure than
participants taught by traditional methods. The overall differences in scores for the
experimental group, as expected, indicate greater performance knowledge levels for the
Open Cricothyrotomy.
In addition to procedural action step knowledge, a key goal of CTA is to capture
the decisions surgeons make more accurately. For this study, essential decisions
participants made during the Open Cricothyrotomy procedure were assessed with a
written post-test. On this measure, the experimental group outperformed the control
group when conveying the decisions they would apply under particular circumstances.
Hypothesis 2 was again supported; participants in the CTA-based instruction group
40
demonstrated more procedural knowledge on a post-test measure than
participants taught by traditional methods.
Limitations
The study had a number of limitations, particularly with data collection in a
setting where human behavior is not easily controlled.
Unscripted Instruction
The intent of the structured course for the experimental group was to have the
instructor carefully follow the GEL, CTA-based script. While the CTA-based curriculum
instructor had been given specific directions to follow the script, the instructor
supplemented the course content with unscripted content (particularly conceptual
knowledge) in between teaching the CTA-based Gold Standard steps and tasks. This
additional instruction beyond what was called for by the study may have confounded the
results. For future studies, it would be helpful to provide the experimental group
instructor with more training on the CTA-based curriculum and a more complete
description of the processes and procedures he or she is expected to follow. Developing a
CTA-based curriculum that provides the instructor with a script is a step in the right
direction to help standardize the information being presented in the classroom. However,
instructor involvement in developing instructional support materials from the outset may
increase the commitment the instructor has to the script. The instructor who taught the
CTA-based course was not involved in creating the script, but was provided only the
opportunity to review and comment on the script a few days prior to the instructional
session.
41
The teaching of unscripted knowledge was also problematic during the
guided practice sessions. Experimental group instructors were asked to use the
procedural checklist closely as their guide to assist students with the practice session.
However, what actually occurred was that each instructor provided added feedback that
was not within the Gold Standard. Although their feedback may have been relevant to
the domain and procedure, it was disruptive to the study because instructors discussed
problems, conceptual knowledge and equipment that was not included in the Gold
Standard. A more complete description of the processes and procedures the instructors
were expected to follow provided prior to the study would have been beneficial.
Participant Behavior
The behavior of students was also not easily controlled during the study. Seven
participants did not sign up prior to the session and had to be assigned to study groups
on-site. Some students did not report to the Surgical Skills Center to be assigned to the
groups, but instead followed their normal instructor, who was not one of the
session/group instructors and who happened to go to the control group’s classroom to
observe the session. This resulted in disproportionate numbers in the control group
versus the experimental group.
When potential participants arrived after instruction had begun, it was difficult to
brief them on the study procedures without causing disruption. During the instructional
session, three students reviewed the procedural checklist, which they should not have
reviewed prior to being assessed. During the guided practice session, several of the
students in the experimental group did not use the job aid as a guide; instructors at each
42
practice station should have required this in order to reinforce the CTA-based
curriculum. After all data were collected, it was discovered that seven students in the
control group did not practice on a model during the guided practice session. They
watched others, but they did not actually practice themselves, because their guided
practice instructor spent too much time discussing domain-relevant information that was
not necessarily on the job aid.
Many of these issues could have been preempted at the start of the study by
presenting clearer instructions to the participants, which could have been available in
writing to accommodate latecomers. Prior to the study, the itinerary and expectations for
the day of the study could have been distributed to participants.
Simulated Performance
Another limitation of the study is that it did not evaluate performance on a live
patient. Since this procedure is not common and only occurs in emergency contexts,
assessing performance on an Open Cricothyrotomy in a real life situation was not
possible. Furthermore, there was no long-term outcome assessment. The participants
were not evaluated weeks or months later to determine if they had retained knowledge
acquired during the course. A follow up assessment could support previous findings that
CTA-based instruction improves transfer when compared to traditional instructional
methods (Maupin, 2003; Velmahos et al., 2004). In addition, the study only collected
data on one procedure with a limited number of participants. More studies with larger
cohorts are recommended to further assess the effectiveness of CTA in surgical skills
instruction.
43
Finally, making generalized conclusions on the effects of CTA-based
instruction based on a three-hour experience is difficult. Conducting CTA interviews,
coding documents and creating instructional materials is extremely time consuming, and
it is difficult to get expert surgeons who are exceptionally busy to focus on, and make
time for, curriculum development. Future research should focus on strategies to
streamline the CTA process; this could include more efficient ways to collect expert
interviews and to use technology to speed up the process of coding and synthesizing
expert interview data.
Summary
Results indicate that CTA-based instruction improves the procedural knowledge
and performance of learners compared to a control group taught with traditional methods.
The study supports a growing body of research that confirms CTA as an effective tool for
eliciting expert knowledge and for informing instruction to improve learning outcomes. It
exemplifies how CTA can inform effectively the development of valuable assessment
tools that can be used as standard evaluations for surgical procedures. The unique
attribute of CTA-based assessment tools, such as the surgical skills checklist, is that it
includes and assesses automated procedural knowledge often untapped and not assessed
by traditional behavioral-based assessments. This study provides the participating
medical school and surgical experts with a procedural Gold Standard, curricular materials
and assessment tools for future use and refinement. The expert surgeon instructors who
participated in this study now have a greater understanding of CTA-based instruction and
its significance to outcomes improvement.
44
CONCLUSION
The focus of this study was to investigate CTA as an effective strategy to improve
surgical skills instruction. This was accomplished by analyzing the performance of an
Open Cricothyrotomy by participants who received traditional expert-led instruction to
the performance of participants who received CTA-based instruction that was crafted
using a GEL model. The results of this study reveal how CTA-based instruction has a
significant positive effect on procedural knowledge and performance. In medicine,
research indicates that the traditional apprenticeship model provides experience, but lacks
a uniform approach to content development, instructional strategies and standardized
assessment that ensure vital expert knowledge is fully and effectively conveyed. Experts
are limited by the nature of automaticity, which inherently results in them omitting
essential knowledge required for novices’ successful task performance. When experts are
in the role of instructor, the goal is to maximize how novices learn by providing a
complete picture of the concepts, processes and principles necessary for successful task
completion. CTA accomplishes this task by eliciting experts’ underlying actions and
decisions often absent in traditional curricular models. It is this complete and accurate
picture of knowledge that makes CTA an essential strategy for expert training for novices
– it informs and strengthens instructional design, including processes for effective
instruction, guided practice, and standardized assessments. In turn, this supports mastery
learning for novices.
45
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50
APPENDIX A
PARTICIPANT DEMOGRAPHIC DATA SURVEY
Student Code: _______
Student Group: A B
Cognitive Task Analysis Survey for Open Cricothyrotomy Training
Current year of: Residency 2 3
Medical School 3
Gender: Female Male
My past training has prepared me for this procedure. Yes No Not Sure
Have you ever performed, assisted or observed an open cricothyrotomy procedure?
Performed? No Yes If yes, how many in the duration of your training? _______
Assisted? No Yes If yes, how many in the duration of your training? _______
Observed? No Yes If yes, how many in the duration of your training? _______
51
APPENDIX B
CTA GOLD STANDARD FOR OPEN CRICOTHYROTOMY
Procedure Title: Open Cricothyrotomy
1. Objective
Establish a definitive airway in an emergency situation (U10; V70, V72; V74;
W36; X8, Y16, Z58) as a last resort (W168)
2. Reasons
Gain airway access in an emergency situation (U17, X32, Y22-23, Z58) when
oral tracheal intubation fails (U17; V58; X35; Y29-30; Z69, Z80, Z feedback
09/08/09)
Risk(s) of not performing well:
o Certain mortality (W51; Y25)
o Patient may be hypoxic longer (W49; X26) and may suffer anoxic brain
injury (X feedback 09/30/09)
o Damage to vocal cords and larynx (U 254; X28)
3. Conditions
Indications:
Loss of airway (U29, U488; V79; Y28-29; W48; Z69, Z feedback 09/08/09)
Multiple attempts at oral tracheal intubation fails (U487; V82-84; V329-330;
V331-332; W54; X35; Y29-30; Z69, Z80, Z feedback 09/08/09)
Facial injuries make it impossible to maintain an airway (U31; V80-81; Y39)
Contraindications:
Able to establish an oral endotracheal airway (V95; Z Feedback 11/29/09)
You do not know how to do the procedure (V102)
You do not have a scalpel and a tube (V103)
52
APPENDIX B continued
Children under10 years of age (Z83, Z feedback 09/08/09; Z feedback 10/06/09;
Z feedback 11/29/09)
Patient has advanced directive not to be resuscitated (Y47-48)
4. Standards
Time: From 1 minute (U63; W73; Z95) to under 5 minutes (V138; Y62; X
feedback 09/30/09)
Vertical incision is between 1.5 to 2.5 centimeters in length (U158; X11-12;
Y114; Z281)
Observable indications of successful procedure:
o Intubation of the trachea (W79)
o Tracheostomy tube inserted just beyond the balloon (W553)
o CO
2
return from patient (U410; W82; Y88, Z102, 103)-- CO
2
detector
should change color (V183; Y89) from purple to yellow/gold (X feedback
10/26/09, X feedback 12/10/2009; Z feedback 11/29/09)
o Improvement in patient oxygenation (U460; W593; Y90-91)
o Audible, bilateral breath sounds (U48; W591; Y93)
o Visual confirmation of the patient’s chest rising (U49; V573; Y94-95)
o Fog in tube (U52; V573-574)
5. Equipment
Mandatory
o Blade/Knife/Scalpel (U69; V170; W93, W643, W649; X46; Y36; Z125, Z
feedback 09/08/09)
o Tube (U69): Choose one of the following based on availability (X
feedback 09/30/09)
Tracheostomy tube (U151; X149; Y65; Z126) sized 6.5 mm, 7
mm, and 7.5 mm (V152; W94); or
Endotracheal tube (U310; W95-96; X149; Y65; Z126; Z329) size
six or smaller (X149); or
Cricothyroid cannula (X168, Y323)
53
APPENDIX B continued
Recommended
o Surgical tray (Y64)
o Tracheostomy Kit (U75; V171; Y76, Z129) / cricothyrotomy kit (V375;
W91)
Tracheostomy tube or endotracheal tube (V182; V758; X149, Y65,
Z126, Z329)
Cricothyroid cannula (V180; X168, Y323)
Connecting piece from tracheostomy to ventilator (Y66)
Tracheostomy hook (U73; V173, V feedback 11/13/09; W128;
X50; Z67)
Trachea tape (W576; X feedback 09/30/09); Y166)
Tracheostomy collar (V177; X feedback 09/30/09)
10 cc Syringe (V163; Y321)
Airway extender / extension tubing (V181; V feedback 11/13/09)
o 3-0 nylon (X feedback 12/10/09) sutures (U420; V176-177; W424; X87,
X feedback 09/30/09; Y242; Z131) and cutting needle (X feedback
12/10/09)
o 4x4 gauze (W547; X85; Y67; Z135)
o Clamp (Z132) or Kelly hemostat (U73; V175; W129; Y76; Z309)
o Small retractor (X49; W131) – optional (X83)
o Chlorhexidine (U146, X feedback 10/26/09) or betadine (U146)
o Drapes (Z184)
o Rolled towel (V164; Y183; Z172)
o Lighting (X195, Z137)
o Suction (W220; Y67)
54
APPENDIX B continued
o Universal barrier precautions
Eyewear (V444; U585; W257; Z187)
Hat (Z187)
Mask (W257; Z187)
Gown (V444; U590, W257; Z188)
Sterile gloves (V416; U590, W257; X feedback 10/26/09, Z
feedback 10/06/09)
o Pulse oximeter (Z118)
o CO2 detector (U575; V184, V feedback 11/13/09; W82; Y87)
o Bronchoscope (U56; Y421; Z108)
o Stethoscope (X feedback 10/26/09)
o Chest x-ray (U51; V feedback 11/13/09; W595)
o Recommended: Assistant to provide retraction/apply pressure (U259;
V410; W128; X47; Y359; Z168)
o Ambu bag (U564)
o Ventilator / oxygen source (U379; V182, V727; W570-571)/ airway team
(V411)
6. Task List
1. Prepare equipment, patient, and self (U75, U84; U590; V164-183; V378-79;
W186; X62; Y101-102, Y391-393; Z14, Z148)
2 Make incisions and open airway (U159; V458; W396; X62; Y119-123; Z156)
3. Place tube in airway (U293, U317; V534; W186; X71; Y124; Z157)
4. Confirm placement and secure the tube (U381; V676; W424, W186; X165;
Y238-243; Z160)
7. Procedure Steps
Task 1: Prepare equipment, patient, and self (U75, U84; U590; V164-183; V378-79;
W186; X62; Y101-102, Y391-393; Z14, Z148)
55
APPENDIX B continued
Step Actions and Decisions
1.1 Locate cric/tracheostomy kit (V374), blade (X62; Y101; Z feedback 9/8/09) and
tubes (X82; V378-379; Z feedback 9/8/09) -- tracheostomy tube (U151; X149;
Y65; Z126) sized 6.5 mm, 7 mm, and 7.5 mm (V152; W94); or endotracheal tube
(U310; W95-96; X149; Y65; Z126; Z329) size six or smaller (X149)
1.2 Select tube (U197; W105)
IF you have only tracheostomy tubes THEN select the tracheostomy tube and go
to step 1.3.
IF you only have endotracheal tubes THEN select the endotracheal tube and go to
step 1.4
IF you have both tracheostomy and endotracheal tubes THEN select the
tracheostomy tube and go to step 1.3 (Z feedback 11/29/09)
1.3 Prepare and test tracheostomy for working cuff (Y325) by attaching balloon to
10cc syringe (V456), blowing-up cuff, and deflating cuff (Y320-322). Pull inner
cannula out of the tracheostomy tube and put the obturator into the tracheostomy
appliance (U298-299; Z338; Z feedback 10/06/09). Go to step 1.4
1.4 Assemble CO2 monitor onto bag (V566; Y352)
1.5 Obtain assistance if possible (U259; V410-412; Y47; Z150, 168)
1.6 Position lights (Z171)
1.7 Position patient (Y102; Z177, 248) into supine position (U164; Y188; Z177, 248)
with patient’s arms at their side (V392-393)
IF patient is at risk of C-Spine injuries, THEN provide C-spine immobilization to
secure patient neck from moving (V104-106; Y104-106, Y408-410; Z feedback
10/06/09) or keep patient in a neutral position (U103). Go to step 1.8.
IF patient has no C-spine injuries, THEN place a rolled towel underneath patient
shoulders to open up neck (V164-165; V169-170, V feedback 11/13/09;Y183-
184; Z172)
1.8 Prepare self by donning universal safety precautions (U585, U593; V441; V444;
V834; W252; Z187); scrubbing hands is unnecessary because of time constraints
(Z444)
1.9 Prepare the neck (U150; V feedback 11/13/09; Z171) with chlorhexidine or
betadine (U152, X feedback 10/26/09) and drape the patient (Z184). Local
anesthetic is unnecessary (Z477).
56
APPENDIX B continued
1.10 Position self for the procedure (Y391-393, 396).
IF you are right-handed, THEN position yourself to the patient’s right side (Y391-
393).
IF you are left-handed, THEN position yourself to the patient’s left side (Y396).
Task 2: Make incisions and open airway (U159; V458; W396; X62; V458; Y119-123;
Z156)
Step Actions and Decisions
2.1 Use non-dominant hand to hold the trachea still (U157; W380-381; X103;
Y108-109)
2.2 Identify the location to make the incision (U99; X63; Y132-133) by using the
dominant hand to palpate through the skin (Z266) and feel for cricothyroid
membrane and thyroid cartilage (Adam’s Apple) (U118, U111, U117; V452-
454; V feedback 11/13/09; w feedback 11/14/2009; Y111-112), either by going
inferior to the Adams’s apple (X95) or by going three or four fingers up from
the sternal notch (U119, U121; W3640366; X96)
2.3 Make a vertical incision 1.5 cm to 2.5 cm in length in the area between the
thyroid cartilage and cricothyroid cartilage (U158; V458, V465-466; V473;
W396; X111; X feedback 09/30/09; Y114, 208; Z281) centered over the top of
the cricothyroid membrane (Z266). Bluntly dissect down past the soft tissue
(X113) to expose thyroid cartilage and cricothyroid cartilage (Y213-215)
2.3.1 IF patient is obese THEN make a longer incision (Y203-204; X
feedback 10/26/09; Z feedback 10/06/09) and go to step 2.3.2
IF the patient is not obese THEN go to step 2.3.2
2.3.2 IF you do not have an assistant (W468) THEN make the incision long
enough that it opens up on its own (W469) and go to step 2.3.3
IF you do have an assistant THEN go to step 2.3.3.
2.3.3 IF there is bleeding and you cannot see (W449) any landmarks such as
the trachea (X feedback 12/10/09) THEN use palpation (W451, W549)
or gauze (W548) but continue to step 2.4 (W547)
IF there is no bleeding THEN go to step 2.4
57
APPENDIX B continued
2.4 Retract the area (V475-476; W400, W474; X114-115; Y233).
IF you have an assistant (W399) THEN have the assistant hold the skin flaps
open (W400) using a Kelly (V475-476) or you can push the skin flaps open
with the blunt end of your knife (V482)
IF you do not have an assistant (W468) THEN push straight back with your
nondominant hand (X feedback 12/10/09) to open the incision (W474)
2.5 Once through the skin and soft tissues, use your finger to feel again to confirm
cricothyroid membrane location (U202; V491-492; W404; Z283; Z feedback
10/06/09)
IF the incision is not over the cricothyroid membrane or the incision is too small
(W452) THEN extend the incision before continuing to step 2.6 (U279; W453-
454)
IF this incision is in the correct location THEN go to step 2.6
2.6 Make a transverse [horizontal] incision across cricothyroid membrane (U204;
V493, V496; W404, W431, W433; Y120, Y223) or penetrate the cricothyroid
membrane with your blade (X116; Z feedback 11/29/09) or the tip of a Kelly
clamp (U feedback 11/15/2009)
2.7 Spread the cricothyroid opening 5-10 mm to fit tube by inserting and twisting
the blunt end of scalpel, inserting and expanding a Kelly inside of the opening
(W405; X116; Y121-123; Z feedback 09/08/09; Z feedback 10/06/09), or
inserting your finger (W406; V496)
Standard: Incision location is correct if you encounter a gush of air (U210,
Z307) and/or observe a small opening (Z308).
IF you get bleeding (X135), THEN apply pressure to stop the bleeding (X136)
but continue to step 2.8 (X140)
IF you do not get bleeding THEN continue to step 2.8
2.8 IF you are placing a tracheostomy tube THEN go to Task 3A.
IF you are placing an endotracheal tube THEN go to task 3B
Task 3A: Place tracheostomy tube in airway (U293; U317; V534; W186; X71; Y124;
Z157)
Step Actions and Decisions
58
APPENDIX B continued
3.1 Optional but recommended: Lift the airway up to facilitate the insertion of the
appliance by inserting the trachea hook from above or below (Z feedback
11/29/09), turning the hook towards the lower part of the tracheal incision, and
pulling the hook up towards yourself (U247; V518-519; V524-525; Z362). If
you do not have a trachea hook, you can make one by bending a large bore IV
needle (V545-546)
3.2 Approach the hole perpendicularly (V534-535), place the tube inside opening
(U185; V534-535; W408; X71; Y234; Z341), twist the tube downwards (V534-
535; X152) and insert the entire length of tube (X feedback 09/30/09) to just
beyond the balloon (W553).
IF the tube does not go in easily or you get a lot of subcutaneous emphysema
THEN remove the tube and repeat step 3.2 (V611-613, V619, V feedback
11/13/09)
IF the tube insertion is successful THEN go to step 3.3
3.3 Hold the tube (U373), remove the obturator (U347; Z342), inflate the cuff to
inflate the balloon (U304, U347; V feedback 11/13/09; W409) and place the
inner cannula into the tube (U372; Z342)
Task 4A: Confirm placement and secure the tube (U381; V676; W424, W186; X165;
Y238-243; Z160)
Step Actions and Decisions
4.1 Connect bag and CO2 monitor to patient (W409; Y238) and bag patient while
ventilator is set up (U380; Y239-241),
4.2 Check for CO2 return (U49; V185, V601; W feedback 11/14/2009; Y239).
IF you are not getting CO2 (W600) THEN make sure the patient did not die
(W600) recheck the tube’s position (W605), extend your incision (W607), look
back into the incision (W607) and make sure you have identified your
landmarks (W607)
IF you are getting C02 THEN go to step 4.3
4.3 Ventilate the patient (V561-563; W570; Y239; Z feedback 11/29/09).
4.4 Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels (W593; Z103)
59
APPENDIX B continued
Check for bilateral breath sounds with stethoscope (U48; W591; X feedback
09/30/09; X feedback 10/26/09) and confirm that chest is rising and falling
(U49; V602)
Optional: Conduct a bronchoscopy (U 50; Z102; Y feedback 10/06/09) or chest
x-ray (U51; V feedback 11/13/09; W595)
4.5 Suction area out once saturation levels have increased (mid 90’s) (Z374, Z
feedback 09/08/09).
4.6 Place a tracheostomy collar around the neck (U676-682; X feedback 09/30/09)
and then suture the collar (U418; V676-682; W583; X167; Y242; Z382) with
3.0 or larger nylon sutures (U418) on a cutting needle (X feedback 12/10/09)
4.7 STOP
Task 3B: Place endotracheal tube in airway (U317)
Step Actions and Decisions
3.1 Optional but recommended: Lift the airway up to facilitate the insertion of the
appliance by inserting the trachea hook from above or below (Z feedback
11/29/09), turning the hook towards the lower part of the tracheal incision, and
pulling the hook up towards yourself (U247; V518-519; V524-525; Z362). If
you do not have a trachea hook, you can make one by bending a large bore IV
needle (V545-546)
3.2 Approach the hole perpendicularly (V534-535), place the tube inside opening
(U185; V534-535; W408; X71; Y234; Z341), twist the tube downwards (V534-
535; X152) and insert the tube between 5 cm (U317) to 10 cm (x feedback
09/30/09) with the balloon barely below the level of the incision (U318; W
feedback 11/14/2009)
IF the tube does not go in easily or you get a lot of subcutaneous emphysema
THEN remove the tube and repeat step 3.2 (V611-613, V619)
IF the tube insertion is successful THEN go to Task 4B
Task 4B: Confirm placement and secure the tube (U381; W424, W186; X165; Y238-
243; Z160)
Step Actions and Decisions
60
APPENDIX B continued
4.1 Connect bag and CO2 monitor to patient (W409; Y238) and bag patient while
ventilator is set up (U380; Y239-241),
4.2 Check for CO2 return (U49; V185, V601; W feedback 11/14/2009; Y239).
IF you are not getting CO2 (W600) THEN make sure the patient did not die
(W600), recheck the tube’s position (W605), extend your incision (W607), look
back into the incision (W607) and make sure you have identified your
landmarks (W607)
IF you are getting C02 THEN go to step 4.3
4.3 Ventilate the patient (V561-563; W570; Y239; Z feedback 11/29/09).
4.4 Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels (Z103) and fogging of the tube
(U52; V602).
Check for bilateral breath sounds with stethoscope (U48; X feedback 09/30/09;
X feedback 10/26/09) and confirm that chest is rising and falling (U49; V602)
Optional: Conduct a bronchoscopy (U 50; Z102; Y feedback 10/06/09) or chest
x-ray (U51; V feedback 11/13/09; W595)
4.5 Suction area out once saturation levels have increased (mid 90’s) (Z374, Z
feedback 09/08/09).
4.6 Suture the tube (U418; U423; W424; X167; Y242; Z382) or tape it to the neck
(U423, W576; X166, X169)
4.7 STOP
Other Information:
8. Conditions & Cues
Emergency situation (U37, X32, Y22-23, Z58) when nasal tracheal intubation and
oral tracheal intubation fails (X35; Y29-30; Z34, Z69, Z80, Z feedback 09/08/09)
Usually performed in a hospital but can be performed anywhere with a tube and
scalpel (U?)
61
APPENDIX B continued
9. Prerequisite Skills / Knowledge
Standard knowledge and skill set of ED residents and surgical residents (U524;
V?; X178; Z34, Z53) and critical care physicians (Y feedback 10/26/09)
Interns can perform this task under supervision (W631)
10. Concepts
A tube secured in the trachea is a definitive airway. A cricothyrotomy is one of
those devices, and the other two being orotracheal intubation and a tracheostomy
(V320-322).
How difficult is to visualize the landmarks (X203)
The cricothyroid membrane is not as pretty as on a mannequin (X206) and is a
solid structure (U250)
How all the equipment works (Z446)
A tracheostomy tube is shorter, has less chance of being dislodged, and is easily
attached to the skin (U428). It is also curved (V525-526)
An endotracheal tube is best for obese patients because the tracheostomy tube
may not be long enough (U308), although it is very rare that the tube is not long
enough (Z feedback 11/29/09)
An ET tube causes you to intubate about 12 cm from where you would intubate
with a tracheostomy tube (U315)
Cricothyrotomy may be taken out and replaced with a tracheostomy, because
having a tube on the cricothyroid cartilage can cause subglottic stenosis (V743-
745; Z215)
Ventilatory management depends on why you place the airway in the first place
(V707-708). Some patients need oxygenation, not ventilation. Some people just
need ventilation, not oxygenation. Some people need both (V713-715). Setting
the ventilator mode depends on the primary problem (V731-732).
When placing the tracheostomy tube, you have to approach the hole
perpendicularly (V530) because if you place it directly in, you’re going to run into
the patient’s chest (V527-528)
ATLS (W252)
02 stats below 90 are significant (W266)
62
APPENDIX B continued
11. Process Knowledge
Assembling cricothyrotomy equipment (Y317-321)
Locating cricothyroid membrane using landmarks and touch (U537; W355; X63;
Y132-133; Z266)
CO2 monitor changing from purple to gold/yellow is a sign of CO2 return (X
feedback 10/26/09, X feedback 12/10/2009; Z feedback 11/29/09)
12. Principles
If tube is too deep, only one side of breath sounds will be heard and the only the
side of the breath sounds will rise. The majority of time the tube will end up in
the right side. Simply pulling the tube back 1-2 cm will do. (Z feedback
12/10/09)
13. Sensory Mode Information
Touch
Feeling for the trachea and cricothyroid membrane location (U87, U202;
V486, V491-492; W363-364, W366, W485; X184; Z283)
Visual
When you insert the endotracheal tube correctly, it will look like the tube
is not completely in (X154, X feedback 09/30/09)
Detecting CO2 monitor colors (U49, U575; V184-185; ?89)
Watching gush of air and blood (U211)
Watching chest rise and fall (U49, U573; V602)
Watching patients’ color change (U577; W277)
View chest x-ray to confirm placement (U50, U579; V feedback 11/13/09;
W596)
See fog in tube (U52; V602)
Seeing if tube is in trachea using bronchoscope (U56; Z102; Y feedback
10/06/09)
63
APPENDIX B continued
Seeing the thyroid membrane or the thyroid cartilage (V454-455; W401,
W664)
Audible Breath sounds (U48, U573; V830; W591; Y93)
The pulse ox monitor has a sound to when the patient’s not oxygenating
(V871-873)
14. Safety Factors
Wear barrier precautions (U585, U590; V441, V444, V834; X192)
Cutting into a vein can cause moderate hemorrhaging (Z404, feedback 09/08/09)
15. Environmental Considerations
Ensure sufficient lighting (Z137)
16. References
None.
17. Problems
Deciding when to do this procedure (Y32). Novices decide that the patient needs
an airway too late (V356; W533) – or perform the procedure too slowly (W533) –
because they start looking for other causes, and really those causes don’t matter.
They fail to realize that A is A, because airway comes first (V362-363).
Lack of experience (V102; Y41-42) or equipment (V103)
Attempting to insert wrong size tube (X159)
If the neck is short or the patient is obese it is more difficult to locate the anatomy
(U119)
Hematoma or a neck injury may distort the anatomy (U126)
Bleeding (W529)
Misidentifying landmarks (U136; W527)
Too small of an incision into the membrane (V589)
Too large of an incision which can transect the larynx (U228)
64
APPENDIX B continued
Letting go of the anatomy with the non-dominant hand and losing site of where to
place the tube (U243)
Inserting the tube into the wrong passage (U335)
Putting an endotracheal tube in too far (U337; W556) and pushing it into the right
main bronchus causing the left lung not to be ventilated (U342)
65
APPENDIX C
INSTRUCTOR SCRIPT LESSON
Table C-1: Lesson Overview
Instructor Activities Student Activities Estimated
Time
Hand out PowerPoint
presentation.
Overview of Open
Cricothyrotomy: Slides 2 – 4
Describe procedure: Slides
5 –18
Receive PowerPoint
handout.
Receive verbal & visual
presentation from
instructor
Observe & ask questions
20 minutes
Demonstrate procedure on
anatomical model
Receive verbal & visual
presentation from
instructor
Observe & ask questions
15 minutes
Hand out Job Aid
Provide Guided Practice
Review Problems: Slide 20
Receive Job Aid
Part task and whole task
practice of the procedure
Receive feedback on
practice
20 minutes
Evaluate resident and student
performance: Slide 21
Receive checklist
evaluation
30 minutes
66
APPENDIX C continued
Open Cricothyrotomy Lesson Script
Slide 1: Introductions
Slide 2: Course Objectives
Introduce the Lesson Goal:
You will learn the open cricothyrotomy, which is performed to establish a
definitive airway in an emergency situation when oral tracheal intubation
fails.
We will review the step-by-step procedure.
I will demonstrate the procedure on an anatomical model.
You will practice the procedure on an anatomical model.
After practice, you will be evaluated performing the procedure on an
anatomical model.
Side 3 Indications and Contraindications:
The indications for the procedure are:
Loss of airway
Multiple attempts at oral tracheal intubation fails
Facial injuries make it impossible to maintain an airway
The contraindications for the procedure are:
Able to establish an oral endotracheal
You do not know how to do the procedure
67
APPENDIX C continued
You do not have a scalpel and a tube
Children under 10 years of age
Patient has advanced directive not to be resuscitated
Side 4 Procedure Overview:
The 4 major Tasks for the Open Cricothyrotomy are:
1. Prepare: equipment, patient, and self
2. Make incisions and open airway
3. Place tube in airway
4. Confirm placement and secure the tube
The procedure should take from 1 minute to under 5 minutes.
Slide 5: Scenario
Explain: I’m going to describe an incident in which I had to perform an open
cricothyrotomy. Together we will review the steps required to successfully
perform the procedure.
Scenario: Instructor, convey an incident in which you had to perform the open
cricothyrotomy procedure describing how you used the following steps:
1. Prepare: equipment, patient, and self
2. Make incisions and open airway
3. Place tube in airway
4. Confirm placement and secure the tube
68
APPENDIX C continued
Slide 6: Task 1 – Preparation: Equipment
Locate and prepare equipment. A full list of equipment is on the last page of your
handout. At a minimum you will need:
Cricothyrotomy Kit
Blade
Tracheostomy tubes – sized 6.5 mm, 7 mm, and 7.5 mm
Rolled towel
Obtain assistance if possible
Position lights
Prepare the tracheostomy tube – INSTRUCTOR DEMOSTRATES:
Test for working cuff using 10 cc syringe:
o Blow up cuff
o Deflate cuff
Pull inner cannula out of the tracheostomy tube and put the obturator into
the tracheostomy appliance.
Assemble CO2 monitor onto bag.
Slide 7: Task 1 – Preparation: Patient
Position patient into supine position with patient’s arms at their side.
IF patient is at risk for C-Spine injuries, THEN:
o Provide C-spine immobilization to secure patient neck from
moving OR
o Keep patient in a neutral position.
69
APPENDIX C continued
IF patient has no C-spine injuries, THEN place a rolled towel underneath
patient shoulders to open up neck.
Prepare the neck with chlorhexidine or betadine and drape the patient. Local
anesthetic is unnecessary.
Slide 8: Task 1 – Preparation: Self
Prepare self by donning universal safety precautions; scrubbing hands is
unnecessary because of time constraints.
Position self:
IF you are right-handed, THEN position yourself to the patient’s right
side.
IF you are left-handed, THEN position yourself to the patient’s left side.
Slide 9: Task 2 – Make Incision and Open Airway: Identify Incision Location
Use non-dominant hand to hold the trachea
Identify incision location
Use dominant hand to palpate through the skin
Feel for cricothyroid membrane and thyroid cartilage (Adam’s Apple),
either by going inferior to the Adams’s apple or by going three four
fingers up from the sternal notch.
70
APPENDIX C continued
Slide 10: Task 2 - Make Incision and Open Airway: Vertical Incision
Make a vertical incision
1.5 cm to 2.5 cm in length in the area between the
thyroid cartilage and cricothyroid cartilage centered over the top of the
cricothyroid membrane.
Bluntly dissect down past the soft tissue to expose thyroid cartilage and
cricothyroid cartilage.
Slide 11: Task 2 - Make Incision and Open Airway: Confirm Location
Retract the area
IF you have an assistant THEN have the assistant hold the skin flaps open
using a Kelly hemostat.
IF you do not have an assistant THEN push straight back with your fingers
to open the incision.
Once through the skin and soft tissues, use your finger to feel again to
confirm cricothyroid membrane location.
IF the incision is not over the cricothyroid membrane or the incision is too
small THEN extend the incision before continuing.
Slide 12: Task 2 - Make Incision and Open Airway: Transverse Incision
Make a transverse [horizontal] incision
Across cricothyroid membrane or
Penetrate the cricothyroid membrane with the sharp end of your blade.
71
APPENDIX C continued
Spread the cricothyroid opening 5-10 mm to fit tube by:
Inserting and twisting the blunt end of scalpel or
Inserting and expanding a Kelly hemostat inside of the opening.
Using your finger is not recommended to avoid injury from cutting
yourself on sharp fragments.
Slide 13: Task 2 - Make Incision and Open Airway: Confirm Location
Standard: Incision location is correct if you:
Encounter a gush of air and/or
Observe a small opening.
IF you get bleeding, THEN apply pressure to stop the bleeding but continue
procedure
Slide 14: Task 3 - Place the tube in airway
Recommended: Lift the airway up to facilitate the insertion of the appliance
by:
Inserting the trachea hook
Turning the hook towards the lower or upper part of the tracheal incision,
and
Pulling the hook up towards yourself
72
APPENDIX C continued
Slide 15: Task 3 - Place the tube in airway
Approach the hole perpendicularly:
Place the tube inside opening,
Twist the tube downwards and
Insert the entire length of tube.
IF the tube does not go in easily or you get a lot of subcutaneous emphysema
THEN remove the tube and try again.
Slide 16: Task 3 - Place the tube in airway
Once tube is in place:
Hold the tube,
remove the obturator,
attach 10cc syringe and inflate the cuff and
place the inner cannula into the tube.
Slide 17: Task 4 – Confirm Placement and Secure Tube
Connect bag and CO2 monitor to patient
Bag patient while ventilator is set up.
Check for CO2 return
CO2 monitor should change from purple to gold
IF you are not getting CO2, THEN
Make sure the patient did not die
Recheck the tube’s position
73
APPENDIX C continued
Extend your incision
Look back into the incision and make sure you have identified your
landmarks.
Slide 18: Task 4 - Confirm Placement and Secure Tube
Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels
Check for bilateral breath sounds with stethoscope and confirm that chest
is rising and falling.
Optional: Conduct a bronchoscopy or chest x-ray.
Suction area out once saturation levels have increased (mid 90’s).
Place a tracheostomy collar around the neck
Suture the collar with 3.0 or larger nylon sutures.
Slide 19: Guided Practice
Hand out job aids.
Explain: Using your job aids, you will perform the open cricothyrotomy
procedure on the anatomical model. You will have some time to practice, and
then an
instructor will observe you performing the procedure without the job aid.
Allow students and residents to practice performing the open cricothyrotomy
procedure on an anatomical model. Provide feedback.
74
APPENDIX C continued
After students have practiced, but before they are evaluated, explain some of the
problems/complications.
Slide 20: Problems/Complications
Explain: Some of the potential problems/complications associated with this
procedure are:
Deciding when to do this procedure. Novices decide that the patient needs
an airway too late – or perform the procedure too slowly – because they
start looking for other causes.
Lack of experience using equipment.
Attempting to insert wrong size tube.
If the patient’s neck is short or the patient is obese, it is more difficult to
locate the anatomy
Hematoma or a neck injury may distort the anatomy
Bleeding
Misidentifying landmarks
Too small of an incision into the membrane
Too large of an incision which can transect the larynx
Letting go of the anatomy with the non-dominant hand and losing site of
where to place the tube
Inserting the tube into the wrong passage
75
APPENDIX C continued
Slide 21: Evaluation
Explain: After guided practice, you will be evaluated performing the open
cricothyrotomy procedure without using the job aid.
76
APPENDIX D
JOB AID FOR EXPERIMENTAL GROUP PARTICIPANTS
Objective: The Open Cricothyrotomy procedure is a procedure performed to establish a
definitive airway in an emergency situation when oral tracheal intubation fails.
Figure D-1: Open Cricothyrotomy Task List
Prepare equipment,
patient and self
Make incisions
and open airway
Place tube in
airway
Confirm placement
and secure tube
77
APPENDIX D continued
Equipment
o Tracheostomy Kit / cricothyrotomy kit
Tracheostomy tube
Cricothyroid cannula
Tracheostomy hook
Trachea tape
Tracheostomy collar
10 cc Syringe
Airway extender / extension tubing
o Blade/Knife/Scalpel
o Surgical tray
o Sutures
o 4x4 gauze
o Clamp or Kelly hemostat
o Small retractor– optional
o Chlorhexidine or betadine
o Drapes
o Rolled towel
o Lighting
o Suction
o Universal barrier precautions: Eyewear, Hat, Mask, Gown, Sterile gloves
78
APPENDIX D continued
o Pulse oximeter
o CO2 detector
o Bronchoscope
o Stethoscope
o Chest x-ray
o Recommended: Assistant to provide retraction/apply pressure
o Ambu bag
o Ventilator / oxygen source / airway team
Task 1: Prepare equipment, patient, and self
Step Actions and Decisions
1.1 Locate and prepare equipment.
1.2 Locate:
Cricothyrotomy Kit
Blade
Tracheostomy tubes –
sized 6.5 mm, 7 mm,
and 7.5 mm
1.1.2 Prepare the
tracheostomy tube(s)
Test tracheostomy for working cuff by testing with a 10cc syringe,
blowing up balloon cuff, deflating balloon cuff.
Figure D-2: Cricothyrotomy Kit
79
APPENDIX D continued
Pull inner cannula out of the tracheostomy tube and put the obturator
into the tracheostomy appliance.
Go to step 1.1.3
1.1.3 Assemble CO2 monitor onto bag
1.3 Obtain assistance if possible
1.4 Position lights
1.5 Position patient
1.5.1 Position patient into supine position with patient’s arms at their side.
IF patient is at risk of C-Spine injuries, THEN provide C-spine
immobilization to secure patient neck from moving or keep patient in a
neutral position. Go to step 1.5.
IF patient has no C-spine injuries, THEN go to step 1.4.2.
1.5.2 Place a rolled towel underneath patient shoulders to open up neck.
1.6 Prepare self by donning universal safety precautions; scrubbing hands is
unnecessary because of time constraints.
1.7 Prepare the neck with chlorhexidine or betadine and drape the patient. Local
anesthetic is unnecessary.
1.8 Position self for the procedure.
IF you are right-handed, THEN position yourself to the patient’s right
side.
IF you are left-handed, THEN position yourself to the patient’s left side.
80
APPENDIX D continued
Task 2: Make incisions and open airway
Step Actions and Decisions
2.1 Use non-dominant hand to hold the trachea still
2.2 Identify the location to make the incision by using the dominant hand to palpate
through the skin and feel for cricothyroid membrane and thyroid cartilage
(Adam’s Apple), either by going inferior to the Adams’s apple or by going three
to four fingers up from the sternal notch.
2.3 Make a vertical incision 1.5 cm to 2.5 cm in length in the area between the
thyroid cartilage and
cricothyroid cartilage centered
over the top of the
cricothyroid membrane.
Bluntly dissect down past the
soft tissue to expose thyroid
cartilage and cricothyroid
cartilage.
2.4 Retract the area.
IF you have an assistant THEN have the assistant hold the skin flaps
open using a Kelly hemostat.
IF you do not have an assistant THEN push straight back with your
fingers to open the incision.
Figure D-3: Vertical Incision
81
APPENDIX D continued
2.5 Once through the skin and soft tissues, use your finger to feel again to confirm
cricothyroid membrane location.
IF the incision is not over the cricothyroid membrane or the incision is
too small THEN extend the incision before continuing to step 2.6.
IF this incision is in the correct location THEN go to step 2.6
2.6 Make a transverse [horizontal]
incision across cricothyroid
membrane or penetrate the
cricothyroid membrane with
the sharp end of your blade.
2.7 Spread the cricothyroid
opening 5-10 mm to fit tube
by:
Inserting and twisting the blunt end of scalpel
or
Inserting and expanding a Kelly hemostat inside of the opening. Using
your finger is not recommended to avoid injury from cutting yourself on
sharp fragments.
Figure D-4: Horizontal Incision
82
APPENDIX D continued
Standard: Incision location is correct if you encounter a gush of air and/or
observe a small opening.
IF you get bleeding, THEN apply pressure to stop the bleeding but
continue to step Task 3.
IF you do not get bleeding THEN continue to Task 3.
Task 3: Place tracheostomy tube in airway
3.1 Recommended: Lift the airway up to facilitate the insertion of the appliance by
inserting the trachea hook, turning the hook towards the lower or upper part of
the tracheal incision, and pulling the hook up towards yourself.
3.2 Approach the hole perpendicularly place the, tube inside opening, twist the tube
downwards and insert the entire length of tube.
IF the tube does not go in easily or you get a lot of subcutaneous
emphysema THEN remove the tube and repeat step 3.2.
IF the tube insertion is successful THEN go to step 3.3
3.3 Hold the tube, remove the obturator, attach 10cc syringe and inflate the balloon
cuff and place the inner cannula into the tube.
83
APPENDIX D continued
Task 4: Confirm placement and secure the tube
Step Actions and Decisions
4.1 Connect bag and CO2 monitor
to patient and bag patient
while ventilator is set up.
4.2 Check for CO2 return.
IF you are not getting
CO2, THEN
o Make sure the
patient did not die
o Recheck the tube’s position
o Extend your incision
o Look back into the incision and make sure you have identified
your landmarks.
IF you are getting C02 THEN go to step 4.3
4.3 Ventilate the patient.
4.4 Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels
Check for bilateral breath sounds with stethoscope and confirm that
chest is rising and falling.
Figure D-5: Bag patient while
ventilator is set up
84
APPENDIX D continued
Optional: Conduct a
bronchoscopy or chest
x-ray.
4.5 Suction area out once
saturation levels have increased
(mid 90’s).
4.6 Place a tracheostomy collar
around the neck and then suture
the collar with 3.0 or larger nylon sutures.
4.7 STOP
Figure D-6: Place tracheostomy collar
around the neck and suture the collar
85
APPENDIX E
PRE-TEST INSTRUMENTS
Student Code: _______
Student Group: A B
Pre-Test - Version 1
Please answer the following questions to the best of your knowledge.
A 54-year old female presents to the emergency room after she was struck in
the face with a baseball bat. Her airway is compromised and she has major
maxillofacial injuries. Endotracheal tube intubation was attempted but not
successful
1. Would you perform an Open Cricothyrotomy at this time? If yes, why?
2. Under what circumstances would you choose NOT to perform an Open
Cricothyrotomy on this patient?
3. What are the risks to this patient during an Open Cricothyrotomy?
86
APPENDIX E continued
4. What would be observable indications of a successful procedure?
5. What complication(s) may result if you place the tracheostomy tube
incorrectly in the patient?
6. During the procedure the patient begins to bleed, what are some of the
reasons this may happen and what would you do?
87
APPENDIX E continued
Student Code: _______
Student Group: A B
Pre Test – Version 2
Please answer the following questions to the best of your knowledge.
A 60-year old male presents to the emergency room by ambulance after a
motor vehicle accident. He is on a backboard with a cervical spine collar in place.
Respirations are labored and endotracheal tube intubation was attempted but not
successful.
1. Would you perform an Open Cricothyrotomy at this time? If yes, why?
2. Under what circumstances would you choose NOT to perform an Open
Cricothyrotomy on this patient?
3. What are the risks to this patient during an Open Cricothyrotomy?
88
APPENDIX E continued
4. What would be observable indications of a successful procedure?
5. What does it mean if the filter in the CO2 monitor turns to gold from
purple?
6. Why should a tube placed during an emergent open Cricothyrotomy be
replaced once the patient transfers out of the emergency room?
89
APPENDIX F
SURGICAL SKILLS PROCEDURAL CHECKLIST
Checklist - Scenario 1
Student Code: _______
Student Group: A B
Scenario 1: A 54-year old female presents to the emergency room after she was struck in
the face with a baseball bat. Her airway is compromised and she has major maxillofacial
injuries. Endotracheal tube intubation was attempted but not successful.
90
APPENDIX F continued
Table F-1: Checklist Scenario 1
Task: I Task:
Not Done (N) Or
Incorrect (I)
Done Correctly Comments
1. Correct reasons for performing
procedure
N I 1
2. Prepare required equipment:
a. Test tracheostomy tube for
working cuff
b. Pull inner cannula out of
the tube and put obturator
into the appliance.
c. Assemble CO2 monitor
onto bag
N I
N I
N I
1
1
1
3. Correct patient position N I 1
4. Prepare patient N I 1
5. Prepare self and position self N I 1
6. Stabilize trachea with non-dominant
hand
N I 1
7. Identify incision location N I 1
8. Make vertical incision
(1.5 – 2.5 cm)
N I 1
9. Retract area with retractor and
confirm cricothyroid location by
touch
N I 1
10. Make transverse incision across
cricothyroid membrane
N I 1
11. Insert tube inside opening N I 1
12. Remove obturator, inflate the cuff
and place inner cannula into tube
N I 1
13. Connect patient to CO2 monitor and
check for Co2 return
N I 1
14. Confirm tube placement N I 1
15. Suction area N I 1
16. Secure tube N I 1
Total:
91
APPENDIX F continued
Were all tasks performed in the correct order? Yes No
If no, which were performed out of order?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Total time to complete tasks 1-17: ________________
92
APPENDIX F continued
Checklist - Scenario 2
Student Code: _______
Student Group: A B
Scenario 2: A 60-year old male presents to the emergency room by ambulance after a
motor vehicle accident. He is on a backboard with a cervical spine collar in place.
Respirations are labored and endotracheal tube intubation was attempted but not
successful.
93
APPENDIX F continued
Table F-2: Checklist Scenario 2
Task: I Task:
Not Done (N) Or
Incorrect (I)
Done Correctly Comments
1. Correct reasons for performing
procedure
N I 1
2. Prepare required equipment:
a. Test tracheostomy
tube for working cuff
b. Pull inner cannula out
of the tube and put
obturator into the
appliance.
c. Assemble CO2
monitor onto bag
N I
N I
N I
1
1
1
3. Correct patient position N I 1
4. Prepare patient N I 1
5. Prepare self and position self N I 1
6. Stabilize trachea with non-dominant
hand
N I 1
7. Identify incision location N I 1
8. Make vertical incision
(1.5 – 2.5 cm)
N I 1
9. Retract area with retractor and
confirm cricothyroid location by
touch
N I 1
10. Make transverse incision across
cricothyroid membrane
N I 1
11. Spread the cricothyroid opening
5-10 mm
N I 1
12. Insert tube inside opening N I 1
13. Remove obturator, inflate the cuff
and place inner cannula into tube
N I 1
14. Connect patient to CO2 monitor and
check for Co2 return
N I 1
15. Confirm tube placement N I 1
16. Suction area N I 1
17. Secure tube N I 1
Total:
94
APPENDIX F continued
Were all tasks performed in the correct order? Yes No
If no, which were performed out of order?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Total time to complete tasks 1-17: ________________
95
APPENDIX G
POST-TEST INSTRUMENTS
Student Code: _______
Student Group: A B
Post-Test - Version 1
Please answer the following questions to the best of your knowledge.
A 54-year old female presents to the emergency room after she was struck in
the face with a baseball bat. Her airway is compromised and she has major
maxillofacial injuries. Endotracheal tube intubation was attempted but not
successful.
1. Would you perform an Open Cricothyrotomy at this time? If yes, why?
2. Under what circumstances would you choose NOT to perform an Open
Cricothyrotomy on this patient?
3. What are the risks to this patient during an Open Cricothyrotomy?
96
APPENDIX G continued
4. How long should this procedure ideally take?
5. What equipment is absolutely necessary in order to perform this procedure?
6. How would you prepare and position yourself to perform the procedure? (be
as complete as possible).
7. How would you prepare and position this patient for the procedure?
8. When you make the initial incision, what length and orientation should it be?
9. What are the indications that your incision location is correct?
97
APPENDIX G continued
10. During the procedure the patient begins to bleed, what are some of the
reasons this may happen and what would you do?
11. How do you know how far to insert the tube in the patient?
12. What complication(s) may result if you place the tracheostomy tube
incorrectly in the patient?
13. What would you do if the patient’s oxygen saturation levels are in the 80s or
lower after inserting the tube?
14. What would be observable indications of a successful procedure?
98
APPENDIX G continued
Student Code: _______
Student Group: A B
Post-Test - Version 2
Please answer the following questions to the best of your knowledge.
A 60-year old male presents to the emergency room by ambulance after a
motor vehicle accident. He is on a backboard with a cervical spine collar in place.
Respirations are labored and endotracheal tube intubation was attempted but not
successful.
1. Would you perform an Open Cricothyrotomy at this time? If yes, why?
2. Under what circumstances would you choose NOT to perform an Open
Cricothyrotomy on this patient?
3. What are the risks to this patient during an Open Cricothyrotomy?
99
APPENDIX G continued
4. How long should this procedure ideally take?
5. What equipment is absolutely necessary in order to perform this procedure?
6. How would you prepare and position yourself to perform the procedure? (be as
complete as possible).
7. How would you prepare and position this patient for the procedure?
8. When you make the initial incision, what length and orientation should it be?
9. What are the indications that your incision location is correct?
100
APPENDIX G continued
10. How do you know how far to insert the tube in the patient?
11. What would you do if the patient’s oxygen saturation levels are in the 80s or
lower after inserting the tube?
12. What does it mean if the filter in the CO2 monitor turns to gold from purple?
13. What would be observable indications of a successful procedure?
14. Why should a tube placed during an emergent open Cricothyrotomy be replaced
once the patient transfers out of the emergency room?
101
APPENDIX H
STATISTICAL ANALYSIS OF PARTICIPANT DATA
Table H-1: Univariate Anova: Tests Between Subject Effects
Dependent variable: pre-test ratio score
ANOVA
Sum of Squares df Mean Square F Sig.
Experience Between Groups .592 6 .099 .414 .860
Within Groups 4.524 19 .238
Total 5.115 25
Gender Between Groups .684 6 .114 .396 .873
Within Groups 5.470 19 .288
Total 6.154 25
102
APPENDIX H continued
Table H-2: T-Test of Independent Means for Total Correct on Pre Test
Group Statistics
Group
N Mean Std. Deviation Std. Error Mean
Pre Test Total
Correct
Experimental 12 5.4167 1.67649 .48396
Control 14 5.5000 1.82925 .48889
Independent Samples Test
Levene's Test for
Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence
Interval of the
Difference
Lower Upper
Pre Test
Total
Correct
Equal
variances
assumed
.057 .813 -.120 24 .905 -.08333 .69273 -1.51305 1.34638
Equal
variances not
assumed
-.121 23.871 .905 -.08333 .68792 -1.50353 1.33686
103
APPENDIX H continued
Table H-3: T-Test of Independent Means for Total Correct on Post Test
Group Statistics
Group
N Mean Std. Deviation Std. Error Mean
Post Test Total
Score
Experimental 12 18.1667 3.61395 1.04326
Control 14 16.7143 2.64367 .70655
Independent Samples Test
Levene's Test
for Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence
Interval of the
Difference
Lower Upper
Post Test
Total
Score
Equal
variances
assumed
.048 .828 1.181 24 .249 1.45238 1.22976 -1.08572 3.99048
Equal
variances
not assumed
1.153 19.868 .263 1.45238 1.26000 -1.17705 4.08181
104
APPENDIX H continued
Table H-4: T-Test of Independent Means for Declarative Knowledge on the Written Post Test
Group Statistics
Group
N Mean Std. Deviation Std. Error Mean
Post Test
Declarative
Knowledge
Experimental 12 14.5000 3.17662 .91701
Control 14 13.8571 2.71342 .72519
Independent Samples Test
Levene's Test
for Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence
Interval of the
Difference
Lower Upper
Post Test
Declarative
Knowledge
Equal
variances
assumed
.000 .996 .557 24 .583 .64286 1.15455 -1.74001 3.02573
Equal
variances
not assumed
.550 21.835 .588 .64286 1.16911 -1.78279 3.06850
105
APPENDIX H continued
Table H-5: T-Test of Independent Means for Procedural Knowledge on the Surgical Skills Procedural Checklist
Group Statistics
Group
N Mean Std. Deviation Std. Error Mean
Checklist Total Correct Experimental 12 17.75 2.340 .676
Control 14 16.00 1.881 .503
Independent Samples Test
Levene's Test
for Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence
Interval of the
Difference
Lower Upper
Checklist
Total
Correct
Equal
variances
assumed
1.087 .307 2.114 24 .045 1.750 .828 .042 3.458
Equal
variances
not
assumed
2.078 21.085 .050 1.750 .842 -.001 3.501
106
APPENDIX H continued
Table H-6: T-Test of Independent Means for Procedural Knowledge on the Written Post Test
Group Statistics
Group
N Mean Std. Deviation Std. Error Mean
Post-test Procedural
Knowledge
Experimental 12 3.6667 .88763 .25624
Control 14 2.8571 .53452 .14286
Independent Samples Test
Levene's Test
for Equality of
Variances t-test for Equality of Means
F Sig. t df
Sig. (2-
tailed)
Mean
Difference
Std. Error
Difference
95% Confidence
Interval of the
Difference
Lower Upper
Post-test
Procedural
Knowledge
Equal
variances
assumed
4.614 .042 .865 24 .009 .80952 .28256 .22636 1.39269
Equal
variances
not assumed
2.759 17.473 .013 .80952 .29337 .19184 1.42720
Abstract (if available)
Abstract
Cognitive Task Analysis (CTA) is a method of eliciting knowledge from experts that can inform more comprehensive instructional support materials for novices. The traditional lecture model that places the expert in the role of instructor, results in a high percentage of missing information due to the nature of expertise characterized by automaticity. A CTA-based curriculum maximizes how novices learn by providing more of the concepts, processes and principles necessary for successful task completion. CTA accomplishes this by eliciting the underlying expert declarative and procedural knowledge (action and decision steps) often absent in traditional curricular models. In surgical skills education, research indicates that the knowledge required for medical students and residents to perform complex procedures accurately and effectively is not being fully conveyed. The long-established apprenticeship model produces well-trained surgeons, but lacks uniformity in content development, instructional strategies and standardized assessment to ensure expert knowledge is fully and effectively conveyed. This study investigates the effects of CTA-based instruction to traditional instruction for medical students and postgraduate surgical residents at a medical research university. The performance of an Open Cricothyrotomy by fourteen participants who received traditional expert-led instruction is compared to the performance of twelve participants who received CTA-based instruction. Results indicate that CTA-based instruction has a significant positive effect on procedural knowledge and performance when compared to traditional expert-led surgical skills education. There was no difference in declarative knowledge between the groups. Limitations of the research and implications for future CTA efforts are discussed.
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Asset Metadata
Creator
Tirapelle, Leslie A.
(author)
Core Title
The effect of cognitive task analysis based instruction on surgical skills expertise and performance
School
Rossier School of Education
Degree
Doctor of Education
Degree Program
Education (Leadership)
Publication Date
05/05/2010
Defense Date
02/08/2010
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
automated knowledge,cognitive task analysis,OAI-PMH Harvest,open cricothyrotomy,procedural knowledge,procedural skills,surgical skills instruction
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Clark, Richard E. (
committee chair
), Sullivan, Maura (
committee member
), Yates, Kenneth A. (
committee member
)
Creator Email
latirapelle@pasadena.edu
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-m3006
Unique identifier
UC172565
Identifier
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Legacy Identifier
etd-Tirapelle-3667.pdf
Dmrecord
328092
Document Type
Dissertation
Rights
Tirapelle, Leslie A.
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Repository Name
Libraries, University of Southern California
Repository Location
Los Angeles, California
Repository Email
cisadmin@lib.usc.edu
Tags
automated knowledge
cognitive task analysis
open cricothyrotomy
procedural knowledge
procedural skills
surgical skills instruction