The Fundamental Use of Surgical Energy (FUSE) Program: Promoting Operating Room Safety

| October 13, 2014 | 0 Comments

by Pascal Fuchshuber, MD, PhD, FACS; Amin Madani, MD; Daniel B. Jones, MD, MS, FACS; and Steven Schwaitzberg, MD

Dr. Fuchshuber, Hepatobiliary and Oncologic Surgery, Associate Professor of Surgery, UCSF, NSQIP Physician Lead, NCAL Region, The Permanente Medical Group, Inc., Walnut Creek, California. Dr. Amin Madani, Division of General Surgery, McGill University, Montreal, Quebec, Canada. Dr. Jones, Professor of Surgery, Harvard Medical School; Vice Chair of Surgery, Office of Technology and Innovation, Chief, Minimally Invasive Surgical Services; Director of the Bariatric Program, Beth Israel Deaconess Medical Center, Boston, Massachusetts. Dr, Schwaitzberg, Chief of Surgery, Cambridge Health Alliance, Cambridge, Massachusetts.

Bariatric Times. 2014;11(10):22–24.

FUNDING: No funding was provided.
DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

This November marks the 10th anniversary of SAGES Fundamentals of Laparoscopic Surgery (FLS) program, the nation’s first hands-on skills assessment test required by the American Board of Surgery (ABS), the national certifying body for general surgeons and related specialists. FLS was created as a first step toward ensuring patient safety and enhancing the innovative treatments that were becoming available in the late 1980s and has been instrumental in single-handedly revolutionizing surgical training worldwide. Since its launch in 2004, nearly 8,500 surgeons have successfully completed the FLS Program. Additionally, last March, the ABS officially announced that graduating general surgery residents in the 2017-2018 academic year must also successfully complete the SAGES Fundamentals of Endoscopic Surgery (FES) program as part of the five-year milestone-based endoscopic curriculum.

On September 23, 2014, SAGES launched the Fundamental Use of Surgical Energy (FUSE), the third SAGES Fundamentals Program. Here we discusses the making of FUSE, its objectives, and curriculum, which will be promoted at ACS Clinical Congress Meeting, in San Francisco, California. The FUSE program is now available online and through SAGES( , FUSE didactics:

FUSE: History and Objectives
What is now the FUSE Program was first envisioned in 2010 by Steven D. Schwaitzberg, then SAGES President-elect. SAGES embraced the idea and supported the creation of the FUSE Program as the third SAGES “Fundamental” program. The impetus for FUSE was based on the startling statistics that about 600 operating room (OR) fires occur annually.[1] Twenty percent of these fires result in disfiguration or death of a patient or caregiver.[2] Additionally, there are approximately 40,000 injuries from burns because of inadequate use of energy devices.[3] Almost all injuries and fires are preventable, and research reveals that few surgeons understand the safe use of energy devices and their impact on patient safety.[4] Dr. Schwaitzberg envisioned a curriculum to teach the safe use of devices in the OR, and he established a core group of surgeons, anesthesiologist, gynecologists, and nurses to address the prevention of iatrogenic injuries and OR fires.

FUSE is a comprehensive multidisciplinary educational program that teaches the appropriate and safe use of all energy devices in surgery and endoscopy. Dr. Daniel Jones, who has been involved in the program since its inception, coined the acronym “FUSE,” which, he says, seems to resonant well.

“It’s really hard to believe that surgeons go into the OR every day and don’t really understand the devices we are using. Once you learn about what happens when we press the “on” button, it’s a little scary to think how easy it would be to burn a tissue where we don’t intend it or to spark an OR fire,” said Jones.

“I have learned a lot about the devices we use in the OR because of my involvement in FUSE. I no longer ‘turn up my bovie to 100. I pay more attention to pacemakers, ICDs, and displacement electrodes. I am more patient with drying my preps and how I coagulate, fulgurate, and vaporize tissues,” Dr. Jones added.
According to Dr. Jones, FUSE is something that is not taught in medical or nursing school, but something that all professionals working with energy devices should know.

The FUSE Curriculum
The FUSE curriculum aims to address the following: 1) fundamentals of energy device usage in surgery, 2) potential risk factors and errors that can occur from inappropriate usage, 3) how to avoid mistakes, and 4) how energy devices might interfere with other medical devices, such as pacemakers.
It contains the following 10 sections:
1.    Fundamentals of Electrosurgery
2.    Mechanisms and Prevention of Adverse Events with Electrosurgery
3.    Monopolar Devices
4.    Bipolar Devices
5. Radiofrequency for Soft Tissue Ablation
6.    Endoscopic Devices
7.    Ultrasonic Energy Devices
8.    Microwave Energy Systems
9.    Energy-Based Devices in Pediatric Surgery
10.Integration of Energy Systems with Other Devices

Photos of The Fuse Curriculum

The FUSE curriculum, which is designed in a true multidisciplinary fashion, is not only used by general surgeons representing a variety of subspecialties, but also by gynecologists, urologists, and anesthesiologists, as well as nurses from the Association of Peri-Operative Registered Nurses (AORN). This program can be used by all surgeons, nurses, and anesthesiologists working in the operative environment where energy devices are used. The program is comprises a FUSE textbook and an online, web-based program that teaches all elements required for safe use of energy devices. The online curriculum takes approximately 4 to 5 hours to complete. This serves as the basis for the FUSE CME and CIU exams. The FUSE exam is validated for maintenance of certification. Exam participants are vigorously tested to measure whether they are adequately trained in the safe use of energy devices.

Dr. Pascal Fuchshuber from the University of California-East Bay, San Francisco, and Kaiser Medical Center, Walnut Creek, California, helped in the development of the FUSE program and curriculum. He became interested when Dr. Jones, who was involved in the program and creation of the FUSE Taskforce at the time, invited him to help organize a session on the safety of energy devices. The session later turned into the FUSE manual, the first step in the creation of the FUSE program.

FUSE is intended to be an educational tool for every person in the OR who uses energy devices on patients during surgery, open, laparoscopic, and endoscopic.
“We want everyone who is using energy devices to do so safely and with proper understanding of the equipment,” said Dr. Fuchshuber.

He also said that with the rapid development of new technologies, FUSE was designed to be a nimble and adaptable tool. The Taskforce aims to update the program frequently to reflect the changing landscape of energy devices. Dr. Fuchshuber hopes that the FUSE program will help to close an important knowledge gap in the safe use of energy device in the operating room and help to improve surgeons’ skills, outcomes, and patient safety.

Dr. Fuchshuber said that the FUSE curriculum is so fundamental and basic to the daily safe practice of endoscopic and operative interventions on patients that the Taskforce believes that every surgeon and allied professional needs to be knowledgeable about it.

“It is a very small investment for a very large benefit,” Dr. Fuchshuber said.
In a recent national address, Dr. Schwaitzberg added, “These fires and energy-based injuries are really team failures. We should be embracing the problem across many disciplines and getting our OR teams on the same page.”

The FUSE program is an important part of the SAGES portfolio of training programs for surgeons and allied health professionals. Participation in the FUSE program is encouraged at the annual SAGES meeting Learning Center, where attendees are taught the fundamental concepts of FUSE with hands-on exercises. Here, attendees learn to understand the fundamental principles of using surgical energy devices, such as radiofrequency energy, electromagnetic field properties, current density and diversion, capacitive coupling, and direct coupling.

FUSE Advocacy and Research
Dr. Amin Madani from McGill University, Montreal, Canada, is an advocate for FUSE around the world. With the help of his supervisor and mentor, Dr. Liane Feldman (co-chair of the FUSE committee at the time), he helped develop a hands-on course on FUSE that is geared toward residency programs throughout the world. This curriculum comprises a one-hour didactic session and a one-hour hands-on simulation. In addition to teaching in the Learning Center, Dr. Madani has traveled to several universities and hospitals throughout the United States, Canada, United Kingdom and Japan, teaching the FUSE course to attendings and residents.

Dr. Madani stated that he believes that FUSE fills a profound unmet need in the surgical community. “We don’t know what we don’t know,” he said of the community’s general knowledge of such devices. It is especially important for residents in training to learn and develop safe practices of these devices early, he said. Dr. Madani, who went through the FUSE certification, said that numerous medical and research facilities consistently ask for FUSE by name, requesting the curriculum and hands-on demonstrations to be provided to their residents. SAGES has made fulfilling these requests a top priority. Dr. Madani said that, from what he has witnessed, people love the program.

“When you show them what can happen, they suddenly become aware, often gasping in shock and disbelief,” Dr. Madani commented.

The initial FUSE concept that fundamental principles of safe and appropriate use of surgical energy are an important part of surgeons’ practice has been shown in several research projects. In one pilot study,4 researchers examined the educational impact of a postgraduate CME course based on the FUSE curriculum at the 2011 SAGES meeting. The course faculty prepared an 11-item multiple-choice examination (pretest) of critical knowledge. The test was administered to members of the SAGES board; Quality, Outcomes and Safety Committee; and FUSE Task Force, and a postgraduate course. The results were as follows: Out of 48 SAGES leaders who completed the pretest, the median percent of correct answers was 59 percent. Thirty-one percent did not know how to correctly handle a fire on the patient; 31 percent could not identify the device least likely to interfere with a pacemaker; 13 percent did not know that thermal injury can extend beyond the jaws of a bipolar instrument; and 10 percent thought a dispersive pad should be cut to fit a child. Pretest results for 27 participants in the postgraduate course were similar, with a median of 55 percent correct. At the end of the course, 25 of them completed a different 10-item post-test, with a median of 90-percent correct.

In a randomized, controlled trial of surgical residents,5 Dr. Madani and colleagues showed that residents participating in a one-hour didactic electrosurgery (ES) course based on the FUSE curriculum significantly improved their knowledge and comfort with the use of surgical energy devices. The participants were randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediate and at 3 months) assessments included knowledge of ES (multiple-choice examination), self-perceived competence for each of the 35 course objectives (questionnaire), and self-perceived comfort with performance of seven tasks related to safe use of ES.

Fifty-six (29 control; 27 Sim) surgical trainees completed the curriculum and assessments. The authors found that the total score on the exam improved from 46 to 84 percent for the entire cohort, with higher immediate post-curriculum scores in the Sim group compared to controls. At three months, performance on the exam declined in both groups, but remained significantly higher in the Sim group. Participants in both groups reported feeling greater comfort and competence post-curriculum (immediate and at 3 months) compared to baseline.

Dr. Madani said that these studies help demonstrate that participants learn and retain the content from the FUSE curriculum, especially when it is combined with a hands-on component.  He encourages his colleagues to take the FUSE exam and also to share their newly acquired knowledge. “It is a matter of everyone taking the initiative to educate themselves.”

In addition, fundamental research6 by Dr. Thomas Robinson, University of Colorado, Denver, Co-chair of the FUSE Task Force, has shed important light on how potential hazardous conditions from surgical energy devices can lead to operator and patient injuries.

The FUSE exam will be available by appointment at the ACS Clinical Congress Meeting, in San Francisco, CA on the following dates: Monday, October 27, 2014, Tuesday, October 28, 2014, and Wednesday, October 29, 2014.

The FUSE program is also now accepting applications from those programs interested in becoming a test center. Visit for more information. For more information on FUSE didactics, please visit

1.    Fuchshuber PR, Robinson TN, Feldman LS. The SAGES FUSE Program: Bridging a patient safety gap. American College of Surgeons. 2014: V99(9).
2.    ECRI Institute. Top 10 health technology hazards for 2012. Accessed April 14, 2014.
3.    Sankaranarayanan G, Resapu RR, Jones DB, Schwaitzberg S, De S. Common uses and cited complications of energy in surgery. Surg Endosc. 2013; 27(9):3056–3072.
4.    Feldman LS, Fuchshuber P, Jones DB, et al. Surgeons don’t know what they don’t know about the safe use of energy in surgery. Surg Endosc. 2012;26(10):2735–2739. Epub 2012 Apr 27.
5.    Madani A, Watanabe Y, Vassiliou MC, et al. Impact of a hands-on component on learning in the Fundamental Use Of Surgical Energy (FUSE) curriculum: A randomized-controlled trial in surgical trainees. Surg Endosc. May 2, 2014. [Epub ahead of print]
6.    Robinson TN, Varosy PD, Guillaume G, et al. Effect of radiofrequency energy emitted from monopolar “bovie” instruments on cardiac implantable electronic devices. J Am Coll Surg. 2014;219(3):399–406.

Tags: ,

Category: Past Articles, Society News

Leave a Reply