Objectives to direct the training of emergency medicine residents on off-service rotations: critical care medicine, Part 1

Redefining emergency medicine procedures: Canadian competence and frequency survey

OBJECTIVE

To redefine the Royal College of Physicians and Surgeons (RCPS) procedural skills list for Canadian emergency medicine (EM) residents through a national survey of EM specialists to determine procedural performance frequency and self-assessment of competence.

METHODS

The survey instrument was developed in three phases: 1) an EM program directors survey identified inappropriate or dated procedures, endorsing 127 skills; 2) a search of EM literature added 98 skills; and 3) an expert panel designed the survey instrument and finalized a list of 150 skills. The survey instrument measured the frequency of procedure performance or supervision, self-reported competence (yes/no), and endorsement of one of four training levels for each skill: undergraduate (UG), postgraduate (PG), knowledge only, or unnecessary (i.e., too infrequently performed to maintain competence).

RESULTS

All 289 Canadian EM specialists were surveyed by mail; 231 (80%) responded, 221 completed surveys, and 10 were inactive. More than 60% reported competence in 125 (83%) procedures, and 55 procedures were performed at least three times a year. The mean competence score was 121 (SD +/- 17.7, median = 122) procedures. Competence score correlation with patient volume was r = 0.16 (p = 0.02) and with hours worked was r = 0.19 (p = 0.01). Competence score was not associated with year or route (residency vs grandfather) of certification. Each procedure was assigned to a training level using response consensus and decision rules (UG: 1%; PG: 82%; unnecessary: 17%).

CONCLUSIONS

A survey of EM clinicians reporting competence and frequency of skill performance defined 127 procedural skills appropriate for Canadian RCPS postgraduate training and EM certification.

A comparison of Australasian and United States emergency medicine training programs

Training programs in emergency medicine differ from country to country. This article compares the allopathic training programs of Australasia and the United States. The perceived advantages of these programs are highlighted, but no attempt is made to determine which is the better program. The Australasian program is significantly longer and places a greater emphasis on the basic clinical sciences, physical examination skills, and academic output. Australasian College for Emergency Medicine (ACEM) regulations are relatively flexible and allow trainees to design their own programs. Trainees are encouraged to arrange accredited positions in a variety of hospitals. Overseas and part-time training may be acceptable. In the United States, trainees rotate within and from one parent institution, which provides a rigid teaching structure for a "critical mass" of trainees, based on a "core" curriculum. Rotations tend to be much shorter but ensure exposure to a broader range of clinical experience. Evaluation of trainees and teaching faculty is more frequent and documentation of procedural and resuscitation skills is required. Trainees are under the close supervision of teaching faculty at all times when working in an ED.

Critical care provided in an urban emergency department

The emergency department (ED) provides a substantial amount of critical care. The purpose of this study was to quantitate the critical care provided in an urban ED. The study was performed at a large urban hospital with an annual ED volume of 70,000 patients. All patients requiring critical care in the ED or hospital were prospectively observed between September 1 and November 30, 1993. Patients requiring recovery room care or neonatal intensive care were excluded. Data collected included age, disposition, length of stay, triage acuity assignment in the ED, primary diagnosis, and critical care procedures. During the study, 11,989 patients were examined in the ED with 500 (5%) requiring admission, 340 (3%) requiring a critical care intervention, and 96 (1%) being admitted to an intensive care unit (ICU). Ten percent of patients receiving critical care in the ED were admitted to the floor for lack of bed space. Triage assignment of emergent life-threatening or urgent potentially life-threatening condition predicted critical care need and waiting time to examination. The spectrum of critical care procedures performed in the ED and ICU were similar except for advanced life support intervention, which was more common in the ED (17 versus 3), and arterial line placement, which was more common in the ICU (14 versus 1). The spectrum of diagnoses reflected the age of patients with cardiovascular illnesses (33%), metabolic illnesses (18%), and trauma (16%) common in adults (age > or = 17) and infectious illnesses (46%) or metabolic illnesses (21%) more common in pediatric patients. Overall, 14% of adult critical care, 23% of pediatric critical care, and 15% of all critical care provided in the areas studied occurred in the ED. A significant proportion of critical care is provided in the ED, and triage acuity assignment reflects this need. A significant proportion of critically ill patients was admitted to the floor for lack of bed space, which highlights the financial constraints in urban hospitals such as the one studied.

The learning needs of first-year surgical residents in the intensive care unit

BACKGROUND

Residents are more likely to learn from educational experiences when properly prepared from the start of instruction and expectations are clear and consistent. The purpose of this study was to examine what first year residents need to know and be able to perform before starting their rotation in the intensive care unit (ICU).

METHODS

The sample included surgical faculty, first through fifth year general surgery residents, and ICU nurses. A survey was developed that listed 110 knowledge and skill items felt to be possible prerequisite learning objectives. Respondents were asked to evaluate the required level of knowledge or skill on a 5-point Likert-type scale.

RESULTS

Items were divided into knowledge or skill categories and then ranked in descending order by their mean ratings. Four knowledge and 10 skill items were ranked highly by all 3 groups of respondents. Kruskall-Wallis analyses found 58 items with statistically significant differences in mean ratings between groups of respondents.

CONCLUSION

With this information a self assessment tool was developed to determine the level of performance on these identified learning objectives. A course of instruction can now be developed to assist residents in meeting these objectives before they assume patient care responsibilities in the ICU.