METHOD: A literature review is performed to discuss fourdifferent practice models for incorporation of physician ex-tenders in an otolaryngology practice. A case study is pre-sented involving physician extenders in an academic otolaryn-gology clinic and the advantages, disadvantages, and costanalysis are reviewed.RESULTS: Mid-level providers may be incorporated in manyfacets and spectra into an outpatient otolaryngology practice.Their adjunctive care is not only cost-effective but has theadvantages of increasing patient education, promoting physi-cian productivity, and improving management of chronic con-ditions. Practice management models that may benefit fromphysician extenders include group or solo practices with highdemand, or those who need improved efficiency. Our casestudy outlines one effective method for incorporating physi-cian extenders into an academic otolaryngologic practice.CONCLUSION: Many models for utilizing physician extend-ers in an outpatient otolaryngology setting are available. Theincorporation of mid-level providers has many advantages andmay be profitable.

Psychomotor Skills Training in Pediatric Airway

Simulation

Noel Jabbour, MD (presenter); James Sidman, MD

OBJECTIVE: 1) To develop a robust psychomotor skills cur-riculum which focuses on teaching the individual componenttasks required to perform the complex psychomotor skill ofpediatric airway foreign body retrieval. 2) To assess the effectof this curriculum on residents’ ability and confidence in per-forming the complete task in an airway simulation laboratory.METHOD: A half-day course was developed to train otolar-yngology residents in pediatric airway endoscopy for foreignbody retrieval. This complex psychomotor skill was decon-structed into smaller task parts. Training was directed towardsgaining competency in each component part of: understandingtracheobronchial anatomy, ability to adequately visualize thelarynx with laryngoscopy, proficiency in flexible and rigidbronchoscopy, and familiarity with foreign body instrumenta-tion. Residents were objectively evaluated on their ability toperform the complete task on a simulator before and after thecourse using an objective assessment of technical skills (OS-ATS) grading system. Confidence in successfully assemblingthe instruments and completing the task was assessed at thesetime periods.RESULTS: Seventeen otolaryngology residents completedthe study. Improvement was measured in multiple OSAT pa-rameters. Confidence in one’s ability to assemble the instru-ments and to perform the complete task increased by an aver-age of 81% and 43% respectively (p�.01).CONCLUSION: The complex psychomotor task of airwayforeign body retrieval can be deconstructed into smaller taskparts that can be independently taught to effectively teach this

complex skill. This curriculum produced significant improve-ment in residents’ ability and confidence and is easily repro-ducible for future simulation training.

Scribe-Assisted Electronic Medical Records (EMR)

Ruthann Lipman, DO (presenter); Robert Budacki,MA; Shannon Gdaniec, RN; Sidney Lipman, MD

OBJECTIVE: 1) Examine a method of real-time physiciandirected, scribe-assisted data entry patient record management.2) Examine the productivity, cost and coding outcomes ofimplementing scribe-assisted electronic medical record(EMR).METHOD: Retrospective pre- and post-EMR implementationcomparison of patient volumes, provider hours spent in patientevaluation, revenue, costs, and appropriateness of documenta-tion for code level billed. The data obtained was from a singlepractice of otolaryngologists in western Pennsylvania (6 phy-sicians, 1 physician assistant). No human subjects were in-volved in this study.RESULTS: Comparison between two equivalent 8 monthintervals (pre- and post-EMR implementation; January-August2008, compared to January-August 2009) was undertaken. A3.6% (729 patients) practice increase in patient volume with acorresponding decrease of 140 provider hours resulting in a32% increase in revenue generated for evaluation and man-agement (E&M) services. The 2009 data revealed an increasein coding levels for E&M visits due to more thorough docu-mentation. Increased costs were noted for computer hardwareand software maintenance, hardware purchases, and personnelto replace those employees re-purposed to the scribe positions.CONCLUSION: Many EMR systems fail to satisfy the needsand desires of modern medical practitioners due to the neces-sity of hands-on data entry by the provider leading to pro-longed involvement of the physician in data management,entry and retrieval. Using this EMR entry method allows forphysician-patient interaction during the visit while eliminatinghands-on data entry by the physician with results includingincreased efficiency, increased exam documentation accuracyand completeness, and a return to patient focused visits withmanageable associated costs.

Teaching Teamwork to ENT Residents Using

Medical Simulation

Jessica Ward (presenter); Noel Irias; AndresNavedo, MD; Jennifer Pollart, RN, BSN, CNOR,BSN; Peter Weinstock, MD, PhD

OBJECTIVE: Develop a curriculum to utilize in situ HighFidelity Medical Simulation (isHFMS) in an actual operatingroom (OR) to: 1) Teach teamwork and Crisis Resource Man-agement (CRM) skills simultaneously to Otolaryngology, An-esthesia and OR staff and trainees. 2) Provide decision making

P41Oral Presentations

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ALS

experience to ENT residents and OR teams in simulated highrisk, low frequency airway emergencies.METHOD: Fifty-three individuals participated in eight simu-lation-based courses given between 10/2008 and 2/2010. Dur-ing each session, the surgical team consisted of Otolaryngol-ogy and Anesthesiology housestaff and 2 OR staff nurses. Theteam members participated together in three simulated medicalcrises which centered on airway and related anesthesia issues.Each simulated crisis was followed by a structured debriefingsession conducted by trained debriefers. Embedded within thecourse were didactics on CRM principles. Upon completion ofeach course, the participants’ reactions to the program weresurveyed using questions with Likert (1-5) scale answers.RESULTS: The participants’ responses on the survey in-cluded: Realism 4.57 (SD� 0.75), Didactics 4.47 (SD�0.80),training session should be taken by all ORL staff 4.71(SD�0.80) Quality of debriefings 4.80 (SD� 0.68) Commentsincluded: ‘. . . the simulator captures the spontaneous feel of acrisis.’ ‘. . . excellent course! Great that this was in our envi-ronment.’ ‘. . . emphasis on leadership, great training for emer-gencies.’CONCLUSION: Employing in-situ High Fidelity MedicalSimulation, a new program was developed to teach airwaymanagement and Crisis Resource Management in the OR.With this curriculum, clinical decision making skills and team-work can be effectively taught concurrently to members of theOtolaryngology, Anesthesia and Nursing teams.

Facial Plastic and Reconstructive Surgery

Cervicofacial Advancement Flap in Midfacial

Reconstruction

Emre Vural, MD (presenter)

OBJECTIVE: The cervicofacial advancement-rotation flap(CARF) can be designed mainly in two different ways basedon the direction of its rotation and advancement, which in-volves an anteromedial (forward) or posterosuperior (reverse)flap movement. Despite the wide utilization of CARF, it hasnot been clearly indicated in the literature when to use whichone of these two main flap designs, especially in the recon-struction of midfacial defects. Objectives of this study are to: 1)Explore the variations in cervicofacial advancement-rotationflap design. 2) Determine the principles for forward or reverseflap design based on the defect proportions and adjacent aes-thetic subunits. 3) Evaluate the results of the application ofthese principles in clinical practice.METHOD: A retrospective review was performed on patientswho underwent CARF reconstruction, and the subset of pa-tients with midfacial defects as described above were included.Each defect was reconstructed according to subunit principles;therefore, cheek defects were reconstructed independently

from adjacent subunit defect(s). The design of the CARF foreventual flap movement (forward or reverse) was selectedbased on the proportions of the defect. CARF was designed ina forward fashion with an anteromedial movement for thedefects with a larger vertical dimension, and in a reversefashion with a posterosuperior movement for the defects witha larger horizontal dimension.RESULTS: Forty-seven patients underwent CARF procedurefor cheek reconstruction. Fourteen of these 47 patients quali-fied for the analysis as a subset based on the location of thedefects as described above. Ages ranged from 38 to 73 yearsold (mean: 56). CARF was used in a forward fashion in eightpatients and in a reverse fashion in six patients. The largestdefect in this subset was measured as 9x6 cm, while thesmallest defect was measured as 3x2 cm. One patient did notfollow-up postoperatively. None of the patients developed par-tial or total flap loss. Six patients had mild ectropion, whichwas managed with massaging, and none of these underwentany corrective eyelid surgery. Ten patients had additional pro-cedures in the form of paramedian forehead flap (eight), skingraft (one) or lower eyelid reconstruction (three), in addition toCARF. The outcome of the reconstruction was satisfactory inall cases.CONCLUSION: Designing the CARF based on the propor-tion of the vertical and horizontal diameters of the midfacialdefects as described in this review allows the surgeon to closethe defects with minimal tension at the superomedial corner ofthe defect and minimizes the amount of discarded healthy skinoverlapping at the suture lines.

Endoscopic-Assisted Craniosynostosis Repair

Ian Heger, MD (presenter)

OBJECTIVE: 1) Understand the role and indications for en-doscopic assisted craniosynostosis repair. 2) Describe the dif-ferent surgical techniques for various types of craniosynosto-sis.METHOD: Describe our indication and experience with min-imally invasive cranial vault repair as well as discuss techniqueand outcomes. Video of the procedure will be shown.RESULTS: Thirty-three infants underwent endoscopic cranio-synostosis repair from 2004 to 2010. This included 4 metopic,16 saggital, and 13 coronal synostosis. All patients scheduledfor endoscopic assisted repair did not require an open approachat the time of surgery. One infant with saggital synostosisrequired re-expansion of the cranial vault through open ap-proach two years later. Data on blood loss and operative time,and length of stay will be presented.CONCLUSION: Endoscopic assisted cranial vault repair is aviable option in management of infants diagnosed early withcraniosynostosis. Postoperative orthotic helmets play an im-portant role in achieving stable long-term outcome.

P42 Otolaryngology-Head and Neck Surgery, Vol 143, No 2S2, August 2010