An unbiased, repeatable process for assessing operating room performance is an important step toward quantifying the relationship between surgical training and performance. Hip fracture surgeries offer a promising first target in orthopedic trauma because they are common and they offer quantitative performance metrics that can be assessed from video recordings and intraoperative fluoroscopic images. Hip fracture repair surgeries were recorded using a head-mounted point-of-view camera. Intraoperative fluoroscopic images were also saved. The following performance metrics were analyzed: duration of wire navigation, number of fluoroscopic images collected, degree of intervention by the surgeon's supervisor, and the tip-apex distance (TAD). Two orthopedic traumatologists graded surgical performance in each video independently using an Objective Structured Assessment of Technical Skill (OSATS). Wire navigation duration correlated with weeks into residency and prior cases logged. TAD correlated with cases logged. There was no significant correlation between the OSATS total score and experience metrics. Total OSATS score correlated with duration and number of fluoroscopic images. Our results indicate that two metrics of hip fracture wire navigation performance, duration and TAD, significantly differentiate surgical experience. The methods presented have the potential to provide truly objective assessment of resident technical performance in the OR.

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Objective-There are no widely accepted, objective, and reliable tools for measuring surgical skill in the operating room (OR). Ubiquitous video and imaging technology provide opportunities to develop metrics that meet this need. Hip fracture surgery is a promising area in which to develop these measures because hip fractures are common, the surgery is used as a milestone for residents, and it demands technical skill. The study objective is to develop meaningful, objective measures of wire navigation performance in the OR.Design-Resident surgeons wore a head-mounted video camera while performing surgical open reduction and internal fixation using a dynamic hip screw. Data collected from video included: duration of wire navigation, number of fluoroscopic images, and the degree of intervention by the surgeon's supervisor. To determine reliability of these measurements, four independent raters performed them for two cases. Raters independently measured the tip-apex distance (TAD), which reflects the accuracy of the surgical placement of the wire, on all 7 cases. Setting-University of Iowa Hospitals and Clinics in Iowa City, IA -a public tertiary academic center.Participants-Seven surgeries were performed by seven different orthopaedic residents. All ten raters were biomedical engineering graduate students.Results-The means and standard deviations for AP, lateral, and combined TAD measurements of the 10 raters were 2.7, 1.9, and 3.7 mm, respectively, and inter-rater reliability produced a Cronbach's Alpha of 0.97. The inter-rater reliability analysis for all 9 video-based measures produced a Cronbach's Alpha of 0.99.Conclusions-Several video-based metrics were consistent across the four video reviewers and are likely to be useful for performance assessment. The TAD measurement was less reliable than previous reports have suggested but remains a valuable metric of performance. Non-experts can reliably measure these values and they offer an objective assessment of OR performance.

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I would like to thank my thesis supervisors Drs. Don Anderson and Geb Thomas for their guidance and support over the past two years. Having professional role models who demonstrate success through example made this achievement possible. Collaboration from orthopedic residents, staff, and surgeons, especially Dr. Matthew Karam with his clinical vision and leadership, was essential to the success of this research. Additionally, I would like to recognize Dr. David Wilder for providing academic support and insight on my committee. I would also like to thank faculty and fellow students in the Orthopedic Biomechanics Lab, whose daily support was indispensable. Finally, I owe the most gratitude to my family; my parents who champion my personal and professional development unconditionally and my husband for always pushing me.

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followings: last dose of chemotherapy received <14 days of death, a new chemotherapy regimen starting <30 days before death, 1 hospital admissions or emergency room visits or hospitalizations >14 days in 30 days of death, or an ICU admission in 30 days of death. Result: 105 patients were enrolled, 38 out of 70 patients (54%) in SOC group and 17 out of 35 patients (48%) in EPC group died. More aggressiveness of care at the EOL (97.3% vs 64.7%, p¼0.003), more in-patient death (89.5% vs 58.8%; p¼0.009) and longer hospitalization before death were observed in the SOC group (12 days vs 4 days, p¼0.028). The cost analysis of patients who died at the hospital showed higher hospitalized cost in the SOC group (p¼0.005). The EPC group received less aggressive treatments such as using less than 3 regimens of chemotherapy (77.1% vs 94.3%; p¼0.028), but the survival rate was not different (11.3 months vs 6.6 months; p¼0.08). Conclusion: Early palliative care reduced the aggressiveness of care at the end of life, shortened hospitalization and covered less cost of treatment.