VALIDATION OF A VIRTUAL CRICOTHYRODOTOMY SIMULATOR VAST-CCT

Di Qi, PhD¹, Uwe Kruger, EngD¹, Nicholas Milef, BS¹, Mohamad R Abu-Nuwar, MD², Mohamad I Haque, MD³, Robert Lim, MD⁴, Daniel B Jones, MD², Melih Turkseven, PhD¹, Emil Petrusa, PhD⁵, Doga Demirel, MSc⁶, Tansel Halic, PhD⁷, Suvranu De, ScD¹, Noelle Saillant, MD⁵. ¹Rensselaer Polytechnic Institute, ²Beth Israel Deaconess Medical Center, ³Anderson Simulation Center, Madigan Army Medical Center, ⁴Tripler Army Medical Center, ⁵Massachusetts General Hospital, ⁶University of Arkansas at Little Rock, ⁷University of Central Arkansas

Introduction: Cricothyroidotomy is a low-frequency yet high-risk emergency procedure conducted to secure a patient’s airway. Traditional training methods offer limited practice opportunities and lack objective and automated assessment. Virtual reality simulation possesses great potential as an alternate training tool overcoming these limitations. A virtual airway skills trainer (VAST) for cricothyroidotomy (CCT), VAST-CCT, was developed to simulate the major steps of CCT. This study aims to assess the face and construct validity of the VAST-CCT simulator.

Methods and Procedures: 47 clinicians were recruited at the 2018 annual conference of the Society of American Gastrointestinal and Endoscopic Surgeons and assigned to one of two groups according to their levels of expertise in CCT: expert (n = 9) and novice (n = 38). The participants performed four critical steps in cricothyroidotomy on the simulator including 1) identifying landmarks, 2) making incision on the skin, 3) puncturing and dilating the cricothyroid membrane, and 4) intubation. Participants’ performance was evaluated based on the overall completion time (seconds) as well as task completeness and accuracy quantified with an overall score, referred to as performance score.

All data (performance scores and completion time) was examined for normality using the Anderson-Darling test. The standard F test is utilized to assess the equality of variances between the novice and expert data. A 2-sample T test (with an equal variance assumption) was used to compare the performance scores between the expert and novice groups, as each sample was drawn from a normal distribution. Due to the non-normal distribution of the completion time, and the data distributions of the expert and novice groups had the same shape (examined using the Kolmogorov-Smirnov test), a Mann-Whitney U test was utilized to compare the completion time between these two groups.

Participants were also asked to comment on the realism of the simulator by answering 9 questions on a five-point Likert-type scale.

Results: Statistical analysis results showed that the experienced surgeons performed significantly better (p = 0.014) and faster (p = 0.007) than the novice group. 75% of the participants reported that the simulator was useful (score of at least 4 out of 5) for training cricothyroidotomy surgical skills and hand-eye coordination ability.

Conclusion: The VAST-CCT simulator showed face and construct validity and thus constitutes a promising tool for training in cricothyroidotomy. Virtual training of such rare and emergent procedure may help ensure competency in a critical skill when limited opportunities exist clinically.