BOA Offices, RCS, London
6th July 2017
I represented trainees at a review of eLogbook operative codes, index procedures and indicative numbers required for T&O CCT. Representatives from all UK T&O subspecialist societies were invited to review and edit their subspecialist codes. The meeting was co-chaired by Mr Bill Ryan (SAC) and Mr Mike Reed (former Education Committee chair). The eLogbook is used in the UK and Ireland and currently contains 32 million operations.
What do we know already?
eLogbook data has proven valuable in the review and monitoring of UK T&O training over the past decade. It was highlighted that eLogbook data can be used to compare the performance of individual trainers, hospitals and training regions. Trainees are listed as the primary surgeon in 80% of trauma operations listed. Old published analysis demonstrated that the implementation of the EWTD had no effect on recorded operations by UK trainees. Old research also compared the old SHO grade with Core Trainees (CTs) who were EWTD compliant or non-EWTD compliant and demonstrated that EWTD compliant CTs had more operative experience compared to the other two groups. Unsurprisingly, the introduction of Major Trauma Centres (MTCs) had a detrimental effect on the number of IM nails performed by trainees not located at an MTC.
What may change?
Validation of recorded operations
Although the original intention was for all trainee operations to be validated by their trainers this is not being done in most regions. Validation will be reviewed by the SAC in the coming months and could become mandatory with the possible introduction of email alerts being forwarded to recorded trainers (either per operation or more likely every few weeks/months).
All current operative codes were reviewed and compared to requests submitted by trainees over the past few years. Edits, deletions and additions were discussed and agreed. Many additions were made across all subspecialties, including ‘application of VAC dressing’, ‘diabetic foot complex reconstruction’, ‘osteotomy of distal radius’, ‘MPFL reconstruction’, ‘Symes amputation’, ‘plantar plate repair’ etc.
In addition, ‘removal of K-wires’ and ‘removal of skeletal traction’ will remain as codes (rarely are codes deleted entirely as other non-training healthcare providers use the same eLogbook for recording procedures) but they will no longer count towards the 1800 cases required for CCT. It was discussed that spinal injections may either not count entirely or be subject to maximum numbers during training. These changes are all subject to further review by the SAC. A decision was made to remove the ‘involvement in operation stages’ options for THR and TKR (e.g. ‘approach to knee joint’ and ‘closure of knee joint’ for TKR).
BOTA highlighted the need to provide greater clarity regarding recording of multiple procedures during the same operation so that trainees can be compared fairly. The system for trainees to submit missing codes should also be made simpler (together with the eLogbook help functionality).
Index procedures and indicative numbers
With the SAC have previously reviewed T&O index procedures and indicative numbers (i.e. the number of completed index procedures required for CCT) it was decided that changes were required. Many trainees lament the fact that 20 first ray procedures are required (and hard to achieve in a 6 month foot and ankle placement) when distal radius fixation is not despite the latter being a clear requirement for a ‘day 1 consultant in the generality of T&O’.and the former only required for subspecialist foot and ankle surgeons. A grid system of competences matched against subspecialty posts/anatomical areas were proposed from the SAC. The index procedures would be broader and there would be fewer linked to a particular anatomical area. For example, IM nailing would include any IM nail (femoral, humeral, tibial) for any indication (not just subtrochanteric subtypes). By and large this broader approach was supported by all present however BOTA highlighted the placement implications and likely frustrations of current trainees at the early years of their higher training.
Another example could be ‘nerve decompression’ which would replace CTD and also include ulnar tunnel decompression, discectomy and others. Despite many index codes becoming uncoupled from a single anatomical area, these competencies would still need to be demonstrated in minimal numbers for key anatomical areas. For example, ‘long bone fixation’ (another possible index code) would need to include minimal numbers in ankle, tibia/femur, humeral, forearm regions to ensure that numbers accurately replicate generalist consultant practice. THRs and TKRs are likely to be retained as the few elective site-specific index procedures. Additional broad competencies were also discussed. BOTA raised the suggestion that trainees achieving PBA level 4 on multiple occasions for a given procedure (e.g. TKR) could be considered for a reduced indicative number (so that trainees can concentrate on their areas of weakness and subspecialist interest). The potential limitations of this approach were considered, including assessment by lenient trainers.
Updated procedures will undergo further scrutiny by the SAC (October 2017) and if agreed will be reviewed by JCST. If JCST accepts these changes a 2-year lead-in window will commence once they publish their support (likely early 2018). According to this timeline the updated competencies will become a requirement for CCT in 2020, affecting current ST3-5 trainees.
The ISCP website will be updated in August this year and will receive accurate and reliable trainee data from eLogbook. This data will be presented as consolidated reports and likely be presented in graphical form. In 2017/18 PBAs will become auto-populated with the number of [X] procedures completed by the trainee to date using eLogbook data. An ISCP App with eLogbook data will be launched in 2018.