Impact of a bedside procedure service on general medicine inpatients: A firm-based trial

Development of a Chief Resident Medical Procedure Service: a 10-Year Experience

BACKGROUND

Lack of experienced faculty to supervise internal medicine (IM) residents is a significant barrier to establishing a medical procedure service (MPS).

AIM

Describe the development and 10-year outcomes of an MPS led by IM chief residents.

SETTING

University-based IM residency program affiliated with a county and Veterans Affairs hospital.

PARTICIPANTS

Categorical IM interns (n=320) and 4th-year IM chief residents (n=48) from 2011 to 2022.

PROGRAM DESCRIPTION

The MPS operated on weekdays, 8 am-5 pm. After training and sign-off by the MPS director, chief residents trained and supervised interns in ultrasound-guided procedures during a 4-week rotation.

PROGRAM EVALUATION

From 2011 to 2022, our MPS received 5967 consults and 4465 (75%) procedures were attempted. Overall procedure success, complication, and major complication rates were 94%, 2.6%, and 0.6%, respectively. Success and complication rates for paracentesis (n=2285) were 99% and 1.1%, respectively; 99% and 4.2% for thoracentesis (n=1167); 76% and 4.5% for lumbar puncture (n=883); 83% and 1.2% for knee arthrocentesis (n=85); and 76% and 0% for central venous catheterization (n=45). The rotation was rated 4.6 out of 5 for overall learning quality.

DISCUSSION

A chief resident-led MPS is a practical and safe approach for IM residency programs to establish an MPS when experienced attending physicians are unavailable.

Evaluating Outcomes and Time Delays of a Non-Trainee-Driven Hospitalist Procedure Service

BACKGROUND AND OBJECTIVES

Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams. We sought to determine the impact of a non-trainee driven , hospitalist-run procedure service relative to time from consult to procedure.

METHODS

The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014-2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained).

RESULTS

Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service.

CONCLUSIONS

A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees.

Characteristics and impact of bedside procedure services in the United States: A systematic review

BACKGROUND

Bedside procedure services are increasingly employed within internal medicine departments to meet clinical needs and improve trainee education. Published literature on these largely comprises single-center studies; an updated systematic review is needed to synthesize available data.

PURPOSE

This review examined published literature on the structure and function of bedside procedure services and their impact on clinical and educational outcomes (PROSPERO ID: 192466).

DATA SOURCES

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, multiple databases were searched for publications from 2000 to 2021.

STUDY SELECTION, DATA EXTRACTION, AND DATA SYNTHESIS

Thirteen single-center studies were identified, including 12 observational studies and 1 randomized trial. Data were synthesized in tabular and narrative format. Services were typically staffed by hospitalists or pulmonologists. At a minimum, each offered paracentesis, thoracentesis, and lumbar puncture. While there was considerable heterogeneity in service structures, these broadly fit either Model A (service performing the procedure) or Model B (service supervising the primary team). Procedure services led to increases in procedure volumes and self-efficacy among medical residents. Assessment of clinical outcomes was limited by heterogeneous definitions of complication rates and by sparse head-to-head data involving suitable comparators. Published data pointed to high success rates, low complication rates, and high patient satisfaction, with a recent study also demonstrating a decreased length of stay.

CONCLUSIONS

There are relatively few published studies describing the characteristics of bedside procedure services and their impact on clinical and educational outcomes. Limited data point to considerable heterogeneity in service design, a positive impact on medical trainees, and a positive impact on patient-related outcomes.

Advancing Internal Medicine Training: Experience of a Bedside Procedure Service as a Resident Elective

BACKGROUND

In 2007, the American Board of Internal Medicine eliminated numeric procedure requirements for licensing. The level of exposure to procedures during residency, and subsequent competence of graduating residents, is variable. In 2015, our institution developed a bedside procedure service (BPS) with the intent to teach ultrasound guidance and procedural training to internal medicine residents with direct supervision of technique by Hospital Medicine faculty to optimize learning, increase confidence, and improve patient safety.

OBJECTIVE

In this study, we review the number and complication rates of resident procedures on a dedicated internal medicine bedside procedure service (BPS) as a resident elective.

METHODS

In this retrospective, observational, single-center study, we reviewed internally collected data from BPS procedures performed from 2015-2019. The BPS offers a variety of procedures done with ultrasound guidance at an adult tertiary care referral center. BPS services are available to all inpatient hospital services. A rotation with the BPS was offered as a stand-alone resident elective for the first time in 2015.

RESULTS

69 residents performed a total of 2700 ultrasound-guided/assisted procedures and 146 diagnostic ultrasound scans from 2015-2019. Residents performed an average of 40 procedures during their elective month. There were 5 resident performed procedural complications with an overall complication rate of 0.19%.

CONCLUSIONS

Our BPS increased procedural opportunities for residents and allowed for real-time feedback by an experienced faculty member in a one-on-one setting. A dedicated rotation allows the time to focus on becoming proficient in invasive procedures with expert supervision.

Medical Procedure Services in Internal Medicine Residencies in the US: a Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

The number of procedures performed by internal medicine residents in the United States (US) is declining. An increasing proportion of residents do not feel confident performing essential invasive bedside procedures and, upon graduation, desire additional training. Several residency programs have utilized the medical procedure service (MPS) to address this issue. We aim to summarize the current state of evidence by systematically evaluating the effect of the MPS on resident education, comfort, and training, as well as patient safety and procedural outcomes in the US.

METHODS

We conducted a systematic review of all studies reporting the use of an MPS with supervision from a board-certified physician in internal medicine residencies in the US. Database search was performed on PubMed, Embase, ERIC, and Cochrane Library from January 2000 to November 2020 for relevant studies. Quality of evidence assessment and random-effects proportion meta-analyses were performed.

RESULTS

A total of nine studies reporting on 3879 procedures performed by MPS were identified. Procedures were safely performed, with a pooled complication rate of 2.1% (95% CI: 1.0-3.5) and generally successful, with a pooled success rate of 94.7% (95% CI: 90.8-97.7). The range of procedures performed by residents under MPS was 6.7-72.8 procedures per month (n = 9) compared to 4.3-64.4 procedures (n = 4) without MPS. MPS significantly increased confidence, comfort, and use of appropriate safety measures among residents.

CONCLUSION

There are a limited number of published studies on MPS supervised by a board-certified physician in US internal medicine residencies. Procedures performed by MPS are generally successfully completed and safe. MPS benefits internal medicine residents training by improving competency, comfort, and confidence.

Procedural Competency Among Hospitalists: A Literature Review and Future Considerations

BACKGROUND

As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience.

METHODS

We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures.

RESULTS

Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists.

CONCLUSION

We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.

Implementation of an academic hospital medicine procedure service: 5-year experience

OBJECTIVES

Procedural complications are a common source of adverse events in hospitals, especially where bedside procedures are often performed by trainees. Medical procedure services (MPS) have been established to improve procedural education, ensure patient safety, and provide additional revenue for services that are typically referred. Prior descriptions of MPS have reported outcomes over one to 2 years. We aim to describe the implementation and 5-year outcomes of a hospitalist-run MPS.

METHODS

We identified all patients referred to our MPS for a procedure over the 5-year span between 2014 and 2018. We manually reviewed all charts for complications of paracentesis, thoracentesis, central venous catheterization, and lumbar punctures performed by the MPS in both inpatient and outpatient settings. Annual charges for these procedures were queried using Current Procedural Terminology (CPT) codes.

RESULTS

We identified 3,634 MPS procedures. Of these, ultrasound guidance was used in 3224 (88.7%) and trainees performed 2701 (74%). Complications identified included pneumothorax (3.7%, n = 16) for thoracentesis, post-dural puncture headache (13.9%, n = 100) and bleeding (0.1%, n = 1) for lumbar puncture, ascites leak for diagnostic (1.6%, n = 8) and large volume (3.7%, n = 56) paracentesis, and bleeding (3.5%, n = 16) for central venous catheter placement. Prior to initiation of the MPS, total annual procedural charges were $90,437. After MPS implementation, charges increased to a mean of $787,352 annually in the last 4 years of the study period.

CONCLUSIONS

Implementation of a hospitalist-run, academic MPS resulted in a large volume of procedures, high rate of trainee participation, low rates of complications, and significant increase in procedural charges over 5 years. Wider adoption of this model has the potential to further improve patient procedural care and trainee education.

Ultrasound-guided Bedside Core Needle Biopsy: A Hospitalist Procedure Team's Experience

Tissue pathology is integral for the diagnosis of various conditions, especially malignancy. Traditionally, biopsy procedures, including core needle biopsy (CNB), are performed by surgeons or radiologists. With the increasing utilization of point of care ultrasound (POCUS) skills and competence in bedside procedures by general internists, CNB can be safely moved to the patient's bedside with maintained accuracy and increased cost savings compared to traditional procedural methods. We aim to review the experience of our hospitalist-run medical procedure service in performing these ultrasound-guided procedures at the bedside.

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Potential impact of a bedside procedure service on training procedurally competent hospitalists in a community-based residency program

BACKGROUND

The Society of Hospital Medicine has delineated procedures as one of the core competencies for hospitalists. Little is known about whether exposure to a medical procedure service (MPS) impacts the procedural certification rate in internal medicine trainees in a community hospital training program.

OBJECTIVE

To determine whether or not exposure to an MPS would impact both the number of procedures performed and the rate of resultant certifications in a community hospital internal medicine training program.

DESIGN

Retrospective review.

METHODS

Five cohorts of resident physicians and their procedure data were analyzed comparing months where residents were unexposed to the intervention (pre-MPS) to months where residents were exposed to the intervention (post-MPS). We calculated the average number of procedures performed per month for pre- versus post-MPS periods. For procedural certification, we compared two proportions: the number of certifications over the number of 6-month pre-MPS periods and the number of certifications over the number of 6-month post-MPS periods.

SETTING/SUBJECTS

The study was conducted at a community-based academic medical center. Subjects included all internal medicine residents.

RESULTS

We found a statistically significant difference between the groups, with pre-MPS groups performing 4.3 procedures per month compared with post-MPS groups performing 6.7 procedures per month (p=0.0010). For certification rates, we found statistically significant differences in several categories - overall, paracentesis, femoral central lines, and jugular central lines.

CONCLUSIONS

This study demonstrated that resident exposure to an MPS statistically significantly increased the total number of procedures performed. This study also showed that overall certification rates were statistically significantly different between the pre- and post-MPS groups for several procedures.

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals

BACKGROUND

Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty.

METHODS

An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty.

RESULTS

There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001).

CONCLUSION

Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

IMPORTANCE

Optimal approaches to teaching bedside procedures are unknown.

OBJECTIVE

To identify effective instructional approaches in procedural training.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.

STUDY SELECTION

We included research articles that addressed procedural training among physicians or physician trainees for 12 bedside procedures. Two independent reviewers screened 9312 citations and identified 344 articles for full-text review.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from full-text articles.

MAIN OUTCOMES AND MEASURES

We included measurements as classified by translational science outcomes T1 (testing settings), T2 (patient care practices) and T3 (patient/public health outcomes). Due to incomplete reporting, we post hoc classified study outcomes as 'negative' or 'positive' based on statistical significance. We performed meta-analyses of outcomes on the subset of studies sharing similar outcomes.

RESULTS

We found 161 eligible studies (44 randomised controlled trials (RCTs), 34 non-RCTs and 83 uncontrolled trials). Simulation was the most frequently published educational mode (78%). Our post hoc classification showed that studies involving simulation, competency-based approaches and RCTs had higher frequencies of T2/T3 outcomes. Meta-analyses showed that simulation (risk ratio (RR) 1.54 vs 0.55 for studies with vs without simulation, p=0.013) and competency-based approaches (RR 3.17 vs 0.89, p<0.001) were effective forms of training.

CONCLUSIONS AND RELEVANCE

This systematic review of bedside procedural skills demonstrates that the current literature is heterogeneous and of varying quality and rigour. Evidence is strongest for the use of simulation and competency-based paradigms in teaching procedures, and these approaches should be the mainstay of programmes that train physicians to perform procedures. Further research should clarify differences among instructional methods (eg, forms of hands-on training) rather than among educational modes (eg, lecture vs simulation).

The impact of a medical procedure service on patient safety, procedure quality and resident training opportunities

BACKGROUND

At some academic hospitals, medical procedure services are being developed to provide supervision for residents performing bedside procedures in hopes of improving patient safety and resident education. There is limited knowledge of the impact of such services on procedural complication rates and resident procedural training opportunities.

OBJECTIVE

To determine the impact of a medical procedure service (MPS) on patient safety and resident procedural training opportunities.

DESIGN

Retrospective cohort analysis comparing characteristics and outcomes of procedures performed by the MPS versus the primary medical service.

PARTICIPANTS

Consecutive adults admitted to internal medicine services at a large academic hospital who underwent a bedside medical procedure (central venous catheterization, thoracentesis, paracentesis, lumbar puncture) between 1 July 2010 and 31 December 2011.

MAIN MEASURES

The primary outcome was a composite rate of major complications. Secondary outcomes included resident participation in bedside procedures and use of "best practice" safety process measures.

KEY RESULTS

We evaluated 1,707 bedside procedures (548 by the MPS, 1,159 by the primary services). There were no differences in the composite rate of major complications (1.6 % vs. 1.9 %, p = 0.71) or resident participation in bedside procedures (57.0 % vs. 54.3 %, p = 0.31) between the MPS and the primary services. Procedures performed by the MPS were more likely to be successfully completed (95.8 % vs. 92.8 %, p = 0.02) and to use best practice safety process measures, including use of ultrasound guidance when appropriate (96.8 % vs. 90.0 %, p = 0.0004), avoidance of femoral venous catheterization (89.5 vs. 82.7 %, p = 0.02) and involvement of attending physicians (99.3 % vs. 57.0 %, p < 0.0001).

CONCLUSIONS

Although use of a MPS did not significantly affect the rate of major complications or resident opportunities for training in bedside procedures, it was associated with increased use of best practice safety process measures.

Specialties performing paracentesis procedures at university hospitals: implications for training and certification

BACKGROUND

Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear.

OBJECTIVE

To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs.

DESIGN, SETTING, PATIENTS

Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals.

EXPOSURE

Patients with liver disease who underwent inpatient paracentesis procedures.

MEASUREMENTS

We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral.

RESULTS

There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001).

CONCLUSIONS

Internal medicine- and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs.

A randomized controlled trial of the impact of a teaching procedure service on the training of internal medicine residents

INTRODUCTION

Academic medical centers must provide safe inpatient procedures while balancing resident autonomy and education. We performed a randomized, controlled trial to evaluate the effect of a 2-week hospitalist procedure service (HPS) rotation on interns' self-perceived procedure ability, knowledge, and autonomy versus the standard curriculum.

METHODS

We randomly selected 16 of 57 internal medicine interns (28%) to participate in the intervention group rotation, with 29 interns in the control group. All interns were surveyed before the start of residency and at the end of the postgraduate year-1 (PGY-1) and PGY-2 years to evaluate self-reported knowledge and ability to (1) safely perform procedures, (2) supervise procedures, and (3) use bedside ultrasound.

RESULTS

Ninety-four percent of HPS interns (15/16) and 71% of control interns (29/41) completed all surveys. Baseline knowledge and experience did not differ significantly between the groups. The intervention group performed significantly more paracentesis (9 versus 4; P < .001), thoracentesis (6 versus 2; P < .001), and lumbar puncture (4 versus 3; P < .001) procedures than did the control group. After their first year, residents who completed the HPS rotation rated their ability to safely perform and supervise all of the assessed procedures as higher (P < .05 for all procedures) and were more likely to rate self-perceived knowledge as very good or excellent in all surveyed aspects of procedure performance (P < .05).

DISCUSSION

A 2-week hospitalist-supervised procedure service rotation substantially improved residents' experience, confidence, and knowledge in performing bedside procedures early in their training, with this effect sustained through the PGY-2 year. Standardized procedure service rotations are a viable solution for programs seeking to improve their procedure-based education.

ACUTE center for eating disorders

BACKGROUND

While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.

METHODS

We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported.

RESULTS

From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero.

DISCUSSION

Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Unexpected collateral effects of simulation-based medical education

PURPOSE

Internal medicine residents who complete simulation-based education (SBE) in central venous catheter (CVC) insertion acquire improved skills that yield better patient care outcomes. The collateral effects of SBE on the skills of residents who have not yet experienced SBE are unknown.

METHOD

In this retrospective, observational study, the authors used a checklist to test the internal jugular and subclavian CVC insertion skills of 102 Northwestern University second- and third-year internal medicine residents before they received simulation training. The authors compared, across consecutive academic years (2007-2008, 2008-2009, 2009-2010), mean pretraining scores and the percent of trainees who met or surpassed a minimum passing score (MPS).

RESULTS

Mean internal jugular pretest scores improved from 46.7% (standard deviation = 20.8%) in 2007 to 55.7% (±22.5%) in 2008 and 70.8% (±22.4%) in 2009 (P < .001). Mean subclavian pretest scores changed from 48.3% (±25.5%) in 2007 to 45.6% (±31.0%) in 2008 and 63.6% (±27.3%) in 2009 (P = .04). The percentage of residents who met or surpassed the MPS before training for internal jugular insertion was 7% in 2007, 16% in 2008, and 38% in 2009 (P = .004); for subclavian insertion, the percentage was 11% in 2007, 19% in 2008, and 38% in 2009 (P = .028).

CONCLUSIONS

SBE for senior residents had an effect on junior trainees, as evidenced by pretraining CVC insertion skill improvement across three consecutive years. SBE for a targeted group of residents has implications for skill acquisition among other trainees.

Reduced resident "code blue" experience in the era of quality improvement: new challenges in physician training

PURPOSE

Emergency resuscitation or "code blue" is a clinical event through which responding medical residents gain experience and proficiency. A retooling of practice has occurred at academic medical centers since the emergence of quality improvement initiatives and resident duty hours limits. The authors investigated how these changes may impact code blue frequency and resident opportunities to gain clinical experience.

METHOD

The authors conducted a single-center, retrospective (2002-2009) review of monthly code blue frequency. They compared code blue frequency with corresponding monthly first-year internal medicine resident call schedules (2002-2008 academic years). Using a Monte Carlo simulation they estimated annual code blue experience, and using Poisson regression, they estimated annual trends in resident code blue experience.

RESULTS

The authors detected a 41% overall reduction in code blue events between 2002 and 2008; code blue events decreased by 13% annually (P < .001). These trends persisted, even after accounting for hospital census fluctuations: Rates fell from approximately 12 code blue events/1,000 admissions in 2002 to 3.8 events/1,000 in 2008. Overall, the model of code blue frequency and resident call schedules shows a dramatic reduction in the predicted number of code blue experiences, falling from 29 events (empirical 95% CI 18-40) in academic year 2002 to 5 events (CI 1-9) in 2008.

CONCLUSIONS

Physicians-in-training at one facility are seeing far fewer code blue events than their predecessors. Whether current numbers of in-hospital code blue events are sufficient to provide adequate experience without supplemental practice for trainees is unclear.

Simulation training and its effect on long-term resident performance in central venous catheterization

INTRODUCTION

Simulation is a safe alternative to practicing procedural skills on patients. However, few published studies have examined the long-term effect of simulation technology on bedside procedures such as central venous catheter (CVC) insertion.

METHODS

To determine whether simulation-based teaching improves procedural comfort, performance, and clinical events in CVC insertion, over traditional methods of procedural teaching, and to assess the long-term effect of this training, we conducted a prospective, randomized controlled trial with 53 postgraduate year-1 and postgraduate year-2 medical residents at a tertiary-care teaching hospital. At the start of the study, we assessed all residents' procedural comfort and previous training and experience with CVCs. We then measured their baseline performance in placing CVCs on simulators, using a validated assessment tool (pretest). For the intervention group, we reassessed performance immediately after simulation training (posttest). All subjects then placed actual CVCs as clinically indicated while on their medical intensive care unit rotations, under the supervision of critical care faculty. We measured clinical events associated with these CVCs. After their medical intensive care unit rotations, we reassessed CVC insertion skills on simulators and procedural comfort of all subjects (delayed posttest).

RESULTS

Intervention subjects demonstrated a significant improvement in skills immediately after simulation training. At delayed posttesting, performance diminished somewhat in the intervention subjects and was not significantly different from control subjects; however, a significant increase over pretest scores persisted in both groups.

CONCLUSIONS

A CVC insertion simulation course improves procedural skills. These skills decline over time, and simulation conferred no long-term additional benefit over traditional methods of procedural teaching.

Long-term retention of central venous catheter insertion skills after simulation-based mastery learning

BACKGROUND

Simulation-based mastery learning (SBML) of central venous catheter (CVC) insertion improves trainee skill and patient care. How long skills are retained is unknown.

METHOD

This is a prospective cohort study. Subjects completed SBML and were required to meet or exceed a minimum passing score (MPS) for CVC insertion on a posttest. Skills were retested 6 and 12 months later and compared with posttest results to assess skill retention.

RESULTS

Forty-nine of 61 (80.3%) subjects completed follow-up testing. Although performance declined from posttest where 100% met the MPS for CVC insertion, 82.4% to 87.1% of trainees passed the exam and maintained their high performance up to one year after training.

CONCLUSIONS

Skills acquired from SBML were substantially retained during one year. Individual performance cannot be predicted, so programs should use periodic testing and refresher training to ensure competence.

Supervising the supervisors--procedural training and supervision in internal medicine residency

BACKGROUND

At teaching hospitals, bedside procedures (paracentesis, thoracentesis, lumbar puncture, arthrocentesis and central venous catheter insertion) are performed by junior residents and supervised by senior peers. Residents' perceptions about supervision or how often peer supervision produces unsafe clinical situations are unknown.

OBJECTIVE

To examine the experience and practice patterns of residents performing bedside procedures.

DESIGN AND PARTICIPANTS

Cross-sectional e-mail survey of 653 internal medicine (IM) residents at seven California teaching hospitals.

MEASUREMENTS

Surveys asked questions in three areas: (1) resident experience performing procedures: numbers of procedures performed and whether they received other (e.g., simulator) training; (2) resident comfort performing and supervising procedures; (3) resident reports of their current level of supervision doing procedures, experience with complications as well as perceptions of factors that may have contributed to complications.

RESULTS

Three hundred sixty-seven (56%) of the residents responded. Most PGY1 residents had performed fewer than five of any of the procedures, but most PGY-3 residents had performed at least ten by the end of their training. Resident comfort for each procedure increased with the number of procedures performed (p < 0.001). Although residents reported that peer supervision happened often, they also reported high rates of supervising a procedure before feeling comfortable with proper technique. The majority of residents (64%) reported at least one complication and did not feel supervision would have prevented complications, even though many reported complications represented technique- or preparation-related problems.

CONCLUSIONS

Residents report low levels of comfort and experience with procedures, and frequently report supervising prior to feeling comfortable. Our findings suggest a need to examine best practices for procedural supervision of trainees.