OBJECTIVE: To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS: Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. RESULTS: Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS: Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.
OBJECTIVE: To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS: Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. RESULTS: Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS: Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.