Wound management curriculum design and implementation evaluation: Evidence from Peking University First Hospital


 Backgroud: It is of vital importance to standardize wound management knowledge and operations in the early stage of resident training. A simulated wound management curriculum for postgraduate Year 1 surgery residents (PGY1s) was designed and its effectiveness evaluated.Methods: We used a quasi-experimental method. PGY1s in 2014 constituted the control group, while PGY1s in 2015 and 2016 constituted the intervention group. The traditional curriculum given to the control group comprised a one-hour lecture plus demonstrations by the instructor, followed by a three-hour practice session. Conversely, the curriculum given to the intervention group included a four-hour curriculum with four components. At the end of each year, the wound management curriculum was evaluated.Results: Subjective assessment showed the intervention group’s scores were significantly higher for dissociation of subcutaneous tissue and quality of suturing and knots. Objective assessment showed there was no obvious improvement in residual marking of incision margin, but the accuracy of debridement depth was greatly improved in the intervention group, the rate of spindle resection decreased and the number of key sutures was significantly higher.Conclusions: The simulated wound management curriculum for PGY1s revealed a generally satisfactory training outcome. It could be implemented in other Chinese universities.

competence-based medical education 3 have become widely practiced. Additionally, surgical training now places more weight on technical skills training, simulation, and learning by doing. In the protected training environment of skills labs, residents are able to continually improve their surgical skills through "mistake for giving" 4 and deliberate practice 5,6 .
In order to implement the standardized training for surgical residents effectively, Peking University First Hospital (PKUFH) set up surgery school in 2014, which is an important innovation in China 7 . And for the first time, plastic surgeons replace general surgeons to taking charge of the wound management curriculum. We taught the postgraduate Year 1 surgery residents (PGY1s) in the traditional pattern in 2014, which includes one-hour lecture plus demonstration followed by three-hour practice, but the summative assessment didn't show a satisfactory results. They can't handle an irregular wound well in a limited time. Considering wound management is an essential skill for PGY1s, because they often act as the first-line doctors dealing with different kinds of wounds either in the emergency situation or in the ward. Therefore, based on our national conditions, we design a wound management curriculum for PGY1s with reference to the US experiences, which basically covers the core skills listed in the US surgical curriculum 8 . The curriculum was applied since 2015, and this study was carried out to evaluate the effectiveness of this new pattern of wound management curriculum.

Study design
The wound management curriculum took place during the fourth month of standardized resident training. It covered surgical skills such as making incisions, tissue protection, tissue dissociation, suturing, and local skin flaps, among others. PGY1s in 2014 constituted the control group, while PGY1s in 2015 and 2016 constituted the intervention group. The same teaching contents were given to both groups but in different patterns. At the end of the first year (seven months after the wound management curriculum), the skills of PGY1s were assessed, and the curriculum was evaluated. All the PGY1s were tested on irregular wound repair (debridement and suture). The assessment criteria were the same for each group of PGY1s, and the test content and scoring criteria were not known to PGY1s beforehand. In the test, an irregular area of 10×3.8cm 2 was marked on cadaveric pork belly skin (Fig. 1A), representing tissue necrosis down to/affecting the deep fascia. PGY1s were required to perform a primary suture after debridement within 15 minutes. Key suture numbers and dog ear treatment were showed in Fig. 1.
[ Fig.1 here] Irregular wound debridement and suture test (from one of the residents). A. the irregular area marked on cadaveric pork belly skin; B. the appearance of the wound after debridement; C. the key suture numbers (the red box) and dog ear treatment (the blue circle).
The examiners included one plastic surgery attending and two general surgery attending, they would receive a brief training by the instructor before the test. They had to make both a subjective and objective assessment of the PGY1s' technical skills of wound debridement and closure. A global rating scale (GRS) was used to assess the performance from six dimensions 9 , namely, "maintaining a sterile field," "knowledge and handling of instrument," "quality of excision," "quality of debridement," "dissociation of subcutaneous tissue," and "quality of suturing and knots," and each dimension was assessed on a 10point scale, the internal consistency reliability turned out to be acceptable 10 . The objective assessment included key suture numbers, residual necrotic tissue condition, resection depth, and dog ear treatment. The average score was calculated as the final score. The instructor remained the same person during three years, which was one of the correspond authors.

Control group
In 2014, the curriculum was arranged as a one-hour lecture plus demonstration followed by three-hour practice session for PGY1s. Feedback was given in the end. The teaching materials were rabbits under general anesthesia.

Intervention group
In 2015 and 2016, the curriculum was conducted as a four-component pilot study with a four-hour curriculum: pretest, didactic teaching, basic surgical skills, and reparation and reconstruction. The teaching materials were cadaveric pork belly skin. The four components were as follows: Component 1: Pretest -Baseline surgical skills assessment (10 mins) Before beginning any teaching, PGY1s were given a pretest to assess their surgical skills so that the curriculum content could be adjusted to their educational needs. The necrotic area was marked on cadaveric pork belly skin (see the black area in Fig. 2A). PGY1s were required to perform a complete excision of the lesion and primary closure of the wound.
The recommended procedure is shown in Fig (Table 2).

Subjective assessment
The results indicate an GRS scores of PGY1s presented anincreasing trend in scores over the three years. The scores of 2015 and 2016 PGY1s were significantly higher than those of 2014 PGY1s for the dimensions of "dissociation of subcutaneous tissue" and "quality of suturing and knots." None of the 2014 PGY1s performed dissociation of subcutaneous tissue, so they scored zero on this dimension. Based on the assessment results in 2015, we reinforced training for "quality of debridement" and "dissociation of subcutaneous tissue" for 2016 PGY1s, leading to the significant improvement of GRS scores. (See Table   3 and Fig. 4) [ Fig.4  Despite the confidentiality of the test questions, the same test questions were used for three consecutive years, which could reduce test efficacy. In addition, mastery learning would be more suitable for the assessment of the curriculum, but ReMERM was not referred to at the beginning of the curriculum design.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors report no conflicts of interest.    Subjective assessment results of postgraduate Year 1 surgery residents over the three years.