Casting is a fundamental technique within orthopedics that is used to fix fractures, help patients with deformities, and immobilize a limb after surgery. For a physician, it’s imperative to not only know how to apply the cast appropriately, but also how to remove it safely.
During cast removal, a cast saw can heat up to the point where it injures the patient by burning their skin. This often results in further, expensive clinical care. But more importantly, it is a painful and avoidable injury to the patient.
Donald S. Bae, MD, an orthopedic surgeon in Boston Children’s Orthopedic Center, is the lead author on an article published in The Journal of Bone & Joint Surgery that details how a simple simulation program dramatically reduced cast-saw injuries.
Simulation training at work
Through a small seed grant from the Program for Patient Safety and Quality, the team created a novel tool that could measure temperatures at the surface of a model used for casting practice – essentially measuring heat on the “skin” of the model. By knowing the temperatures that are associated with pain, as well as burns, this model was used to teach trainees how to remove casts without injuring the patient. “The model is something that’s relatively simple, but still powerful,” explains Bae.
Prior to the simulation training, residents reviewed reading and video materials demonstrating techniques for applying, molding, bivalving and removing casts. They also took part in a lecture on cast application and removal. During the simulation training, residents were given feedback from an attending orthopedic surgeon on both cast application and cast-saw technique. Trainees were instructed to guide the cast saw with in-and-out motions, instead of dragging the blade through the cast – which results in excessive friction and heat build-up that leads to burns. The model allowed for real-time feedback during this procedure, giving residents the maximal temperatures generated on the surface of the simulated skin using a novel task-trainer.
Prior to simulation training, the rate of cast-saw burns per six-month residency cycle at our institution was 4.3 percent. After simulation training, the rate of cast-saw burns dropped to 0.7 percent. Along with the main focus of enhancing patient care, this drop-off in injuries also produced a theoretical return on investment of 11 to 1 – taking into account the lower cost of the simulation program compared to the theoretical medical and legal expenses incurred by cast-saw burns.
Through enhancing training methods at such a low cost, this program effectively supplemented the instruction of a common in-clinic procedure for trainees, and reduced the incidence of these injuries. “If we can teach and train people to provide great care more safely, then it strikes at the heart of our mission,” says Bae.
Currently, this simulation program has been implemented as part of the regular curriculum for all residents rotating through the Orthopedic Center at Boston Children’s. The encouraging results have Bae envisioning a future beyond just one simulation program at one institution. “There’s opportunity for us to use this model at educational meetings for national and international events to train efficacy and safety, or for us to take this model and scale it to use at other venues.”
With the help of the Simulator Program at Boston Children’s, Bae also wants to expand simulation training to other fundamental skills in pediatric orthopedics – whether it’s fracture fixation, treatment of infection or even diagnostic procedures. Expansion of these training programs may help hospitals find simple, cost-effective strategies to achieve the overall goal of improving efficacy and safety.
Learn more about Boston Children’s Orthopedic Center