Improving knowledge of doctors and paramedics through effective bone procurement workshop: A cognitive approach

Background Procurement of bone allograft must be performed by trained personnel. Improper handling and lack of knowledge during bone procurement will lead to contamination hence jeopardizing quality of the procured bones and expose bone recipients to risks of infection in post-operative phase. Bone procurement workshop is the fundamental training programme to enhance skill among personnel who has been or will be involved in bone procurement. This study evaluated the effectiveness of the workshop contents including teaching materials by assessing the knowledge on bone procurement among the participants before and after the workshop. Methods Bone procurement workshop was held for 2 days for doctors and paramedics. The knowledge on bone procurement was evaluated in pre- and post-assessments by answering self administration questionnaire before and after the workshop, respectively. Results A total of 50 participants comprised of doctors and paramedics attended the workshop however only 15 (55.6%) doctors and 12 (44.4%) paramedics completed the assessments. Overall, the mean total score for the post-assessment (61.4%) was significantly higher (p < 0.05) than that of the pre-assessment score (32.2%). The mean values of correct responses for the post-assessment was significantly higher (p < 0.05) than that of the pre-assessment in all five topics given during the workshop. The correct responses for the pre- and the post- assessments in the respective group of the doctors and paramedics were also statistically significant (p < 0.05). In the pre-assessment, the doctors had the highest score in Surgical Approach & Reconstruction (50%) while the paramedics had the highest score in Donor Screening & Selection Criteria (33.3%). In the post-assessment, the doctors had the highest score in Donor Screening & Selection Criteria (70%) while the paramedics in Packaging & Transportation (65.8%). Conclusions The assessment managed to show that the workshop contents and teaching materials were effective in improving the cognitive knowledge of the personnel who would get involved in bone procurement under the National Donation Programme.


Background
Bone grafting has been used in orthopaedic transplantations for more than hundred years [1]. Bone allograft acts as a substitute to bone autograft in orthopaedic reconstructive surgery mainly for providing mechanical support, repairing minor defects and replacing major bone loss in oncology cases [2][3][4].
Bone banking is still not popular among the orthopaedic surgeons despite the increasing usage of allografts in orthopaedic procedures lately [5]. Procedures of bone grafting involving bone procurement, graft preparation and delivery of bone allografts for transplantation is a complex and intricate process with varying practices among different bone banks [3]. Improper handling of procured bones might increase infection risks due to contamination [6].
In Malaysia, bone procurement must be carried out by surgeons namely orthopaedic surgeons under sterile condition. The procured bones are then properly packed by nurses or paramedics. Hence doctors and paramedics are the main players in procuring and storing bone allografts. Competency in procurement technique is vital in order to have high quality procured bone. Therefore they need to be given a special training to develop or improve skill in bone procurement before they are allowed to join bone procurement team in their respective hospitals or at national level. These well-trained personnel can also play an important role in the selection of suitable donors prior to bone procurement [7]. More donors will result in more bones to be procured thus improving bone stock to meet the increasing demand of bone allografts. Both orthopaedic surgeons and paramedics are therefore most eligible to assume the responsibilities of developing and managing a surgical bone bank [8].
Cadaveric bones must be procured in less than 12 h of time of death if the bodies are not refrigerated, and less than 24 h if refrigerated. Procurement is conducted either in operating theatre or mortuary. Preferably, procurement should be carried out immediately as colonization of bacteria will increase after 12 h [9].
Training on bone procurement must be able to provide the opportunity to develop surgical skills under a controlled environment and aseptic handling. By using cadavers, the hands-on session can simulate the actual bone procurement process, hence giving a real experience in handling human bodies. The training sessions would provide optimal opportunity for trainees to develop their competency in bone procurement procedures prior to the real practice and ability to reduce risks of bone contamination hence infection. Use of cadavers in surgical training has been practised for centuries and remains a highly regarded method of training due to the exposure to real anatomy and indeed anatomical variation [10]. Prior to hands-on practical session, a series of lectures were given to improve or enhance knowledge on bone banking, donor selection criteria, procurement technique, proper packaging and labelling.
Knowledge in tissue banking is still low in Malaysia. From our recent survey, only 12.5% of doctors and paramedic attended an orthopaedic conference were aware of the existence of local bone banks [11]. Malaysia has already conducted 2 bone procurement workshops namely in 2013 and 2015, in our effort to increase knowledge and develop more competent procurement team members. The contents of the workshops were further improved when the third workshop was conducted in 2017. Therefore the present study was aimed to assess the effectiveness of the bone procurement workshop, training programme and teaching materials, in improving knowledge for surgeons and paramedics. on Day 2 allowed the participants to conduct bone procurement, processing, packaging and labelling. Fresh frozen cadavers were retrieved from unclaimed bodies by the NTRC and they were kept at 4°C prior to the workshop at Hospital Kuala Lumpur, Malaysia. Four cadavers were used where 6 doctors and 6 paramedics were stationed at each limb. After a demonstration by the main instructor, surgeons were guided to do bone procurement starting from upper to lower limbs. During the workshop, the paramedics were trained for packaging and labelling of the procured bones. Those activities were monitored by instructors who were orthopaedic surgeons and bone bankers. Discussion session on Day 2 covered all ascpects of bone procurement including bones procured from living donors.

Pre and post workshop assessments
Workshop assessment comprised of three parts. Part 1 required participants to write their demographic information: name, gender; age, occupation, current working place and years in service. Part 2 contained questions on knowledge on tissue banking and tissue donation. Part 3 was assessment on bone procurement consisting of ten questions for each of five lecture topics which were presented during the workshop. The questions were multiple choice question where a "Yes", "No" and "Not sure" were options for answer. This study was a pre-post quasi-experimental study to determine the difference score of two groups of participants i.e. doctors and paramedics, before and after attending the the workshop. The pre-assessment was conducted before the participants registered for the workshop. The postassessment was conducted 2 weeks after the workshop allowing ample time for the participants to read lecture notes before answered the questions and to reduce recall bias among the participants. The post-assessment was administered online where participants were contacted via email and telephone. The assessment carried 10 marks for each question and percentage were calculated from the correct answers. A "No" and "Not sure" considered a single answer.

Workshop evaluation
Workshop evaluation form was distributed at the end of the workshops to assess the impacts of the workshop, contents of the programme and lectures related to bone procurement. The participants were required to fill up an evaluation form and submitted immediately after the workshop ended. The workshop evaluation was based on Likert scale points from 1 to 5 with 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. Free-form additional comment was also offered in the evaluation form.

Ethical considerations
All the workshop participants were fully informed that the study was part of the bone procurement workshop. The purpose and the aims of the study were explained to them during registration at the registration counter. The participants were given consent form for declaration to give permission for their feedback and assessment scores to be used only in the study.

Data analysis
All data were analyzed using SPSS software version 24.0 (IBM Corp. Armonk, New York). Demographic and knowledge of tissue banking were reported descriptively by frequency and percentage. Independent sample T-test was used to analyze the pre-and post-assessment scores by the participants within the group and between the two groups. Statistically significant threshold was set at p value ≤0.05.

Socio-demographic characteristics
A total of 21 doctors and 19 paramedics responded to involve in the study which accounted as 84 and 76% of the total participants, respectively. Of these only 15 doctors (71.4%) and 12 paramedics (63.2%) completed the preand the post-assessment. Among the doctors, 9 were surgeons (33.3%) while others were medical officers ( Table 2). In the paramedic group, 7 were medical assistants (25.9%)

Awareness in tissue banking
All participants as shown in Table 3 were aware about organ donation (100%). All doctors were aware about tissue donation compared to only 75% of the paramedic group. Again, all doctors knew about bone banking and only 58.3% of the paramedics knew about it. Majority of the doctors (86.7%) and half of the paramedics (58.3%) were aware about bone procurement. Majority of the doctors (66.7%) and the paramedics (75%) were never involved in bone procurement. Only 8 (29.6%) from the total participants have been involved in bone procurement for less than 5 times (Table 3).

Bone procurement assessment
Based on correct responses, the participants in overall showed improvement in their scores, from only 32.2% in the pre-assessment to 61.4% in the post-assessment ( Table 4). The improvement after the workshop in the total score as well as for all five topics of lectures were statistically significantly (p < 0.05). The doctors showed better performance than the paramedics in terms of the score from 40. There were significant differences between the two groups (p < 0.05) either in the overall score or in each topic of lectures on bone procurement.

Workshop evaluation
Evaluation on the workshop by the participants are summarized in Table 5. The participants mostly agreed with the listed impacts of the workshop when the means were greater than 4 for both the doctors and the paramedics. They also agreed that the workshop provided positive values to bone procurement. There were no statistically significant difference between the two groups in all aspects of the evaluation (p > 0.05). No additional comments were received from the participants.

Discussion
The study revealed that all of the participants were aware about organ donation but not all aware about tissue donation. The doctors were more aware about about bone banking and bone procurement than the paramedics. Future public awareness programme should emphasise on this supporting personnels. In this study the scores for the correct response in the post-assessment were consistently higher than the preassessment indicating that the workshop managed to improve or enhance the knowledge of the participants. According to Beauchamps et al. (2016), the post-assessment rating would be significantly higher than the pre session rating when using integrated format modules including video, cadaveric training (hands on) and lectures [12]. Demographic factors in terms of gender, occupation, years of service and age of participants seemed not to influence the workshop assessments. Knowledge levels between the doctors and the paramedics were found to be inequal in this study. The doctors had higher scores in all topics of the pre-assessment with the highest score was for Surgical Approach & Reconstruction, which is a part of their nature of works. Surprisingly the highest score in the post-assessment for the doctors was in Donor Screening & Selection Criteria which indicated that the workshop managed to provide better understanding and made them more aware the importance of the inclusion and exclusion criteria for tissue donors in bone procurement.
The workshop also improved their knowledge in bone packaging and transportation. The paramedics already had some knowledge in Donor Screening & Selection Criteria based on the score in the pre-assessment as they are the frontliner and directly deal with the donors. The highest score in postassessment by the paramedics was in packaging and transportation indicating that the workshop managed to enhance their knowledge. The paramedics as the technical person are expected to continuously improve their know-how in proper handling of bones during the packaging and transportation to tissue bank. The evaluation for the workshop in relation to the impacts of the workshop in enhancing the knowledge and skill in bone procurement by the doctors and the paramedics were similar. Both groups gave more than 4 indicating they agreed that the workshop contents were relevant and the programme was well organised to suit their expectations. The high rating given by the participants was so crucial to indicate that the workshop was succeded in improving their knowledge and assisting them to develop further their skills in bone procurement.
The assessments were able to evaluate the effectiveness of the bone procurement workshop. The training programme and teaching materials were relevant in improving knowledge and understanding in tissue banking while the hands-on practical class was essential in developing skill in bone procurement. In addition, the workshop provided a platform for the participants to discuss the current issues and to acquire new developments of tissue procurement in particular and tissue donation in general.
Cognitive knowledge on bone procurement was effectively assessed in the study and all aspects of bone procurement were mainly covered. In contrast, technical skill and surgical performance to perform bone procurement need to be assessed separately as more lengthy time and resources such as cadavers are required. Hence, this is the major drawback in the study where quality of the surgical outcome is not able to retrieve.