title: A Novel Cast Removal Training Simulation to Improve Patient Safety.
abstract: OBJECTIVE
  Cast application and removal are essential to orthopedics and performed by providers of variable training. Simulation training and practice of proper cast application and removal may reduce injury, optimize outcomes, and reduce health care costs. The purpose of this educational initiative was to develop, validate, and implement a novel simulation trainer and curriculum to improve safety during cast removal.
  
  
  METHODS
  In all, 30 thermocouples (Omega, Stamford, CT) were applied to a radius fracture model (Sawbones, Vashon, WA). After reduction and cast application, a saw (Stryker, Kalamazoo, MI) was used to cut the cast with temperature recording. Both "good" and "poor" techniques-as established by consensus best practices-were used. Maximal temperatures were compared to known thresholds for thermal injury; humans experience pain at temperatures exceeding 47°C and contact temperatures exceeding 60°C may lead to epidermal necrosis. Construct validity was evaluated by assessing novice (postgraduate year 1), intermediate (postgraduate year 3), and expert (pediatric orthopedic attending) performance.
  
  
  RESULTS
  With the "good" technique, mean peak temperatures were 43°C + 4.3°C. The highest recorded was 51.9°C. With the "poor" technique, mean peak temperature was 75.2°C + 17.3°C. The maximum temperature recorded with the "poor" technique was 112.4°C. Construct validity testing showed that novices had the highest increases in temperatures (12.9°C). There was a decline in heat generation as experience increased with the intermediate group (9.7°C), and the lowest heat generation was seen in the expert group (5.0°C).
  
  
  CONCLUSIONS
  A novel task simulator and curriculum have been developed to assess competency and enhance performance in the application and removal of casts. There was a 32.2°C temperature decrease when the proper cast saw technique was used. Furthermore, the "poor" technique consistently achieved temperatures that would cause epidermal necrosis in patients. Clinical experience was a predictor of decreased heat generation during cast removal. This task trainer allows instruction and safety monitoring of the casting technique.
authors.affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Jacob W
authors.initials: JW
authors.lastname: Brubacher
authors.affiliation: TechEn, Inc., Milford, Massachusetts.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Karg
authors.affiliation: Simulator Program, Boston Children's Hospital, Boston, Massachusetts; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts.
authors.forename: Peter
authors.initials: P
authors.lastname: Weinstock
authors.affiliation: Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts. Electronic address: donald.bae@childrens.harvard.edu.
authors.forename: Donald S
authors.initials: DS
authors.lastname: Bae
mesh_terms: D002370:Casts, Surgical; D003479:Curriculum; D006801:Humans; D008348:Manikins; D009985:Orthopedics / Q000193:education*; D061214:Patient Safety / Q000592:standards*; D058996:Quality Improvement; D000066908:Simulation Training
keywords: Patient Care; Practice-Based Learning and Improvement; orthopedics; patient safety; surgical simulation