medicine procedural skills: What do they need to know? A survey of Canadian emergency medicine residents & program directors Andrew Petrosoniak, Jodi Herold & Karen Woolfrey, Residency Program and Wilson Centre University of Toronto
Disclosure The authors have no conflicts of interest to disclose
Rationale EM physicians must be competent in variety of procedural skills Competency is an increasingly important concept in medical education but its definition is controversial (clinical comfort vs. experience) No well-defined standards for EM procedure training There is a lack of data regarding the current state of procedural experience and training among Canadian EM residents
Objectives Describe the current state of procedural skills training & experience among Canadian FRCP-EM residents Establish program director opinions regarding competence & relative importance from a list of EM procedures
2008 Objectives of Training in EM (FRCP-EM) Procedure list reviewed by 5 EM staff physicians 45 EM procedures + 1 control Procedure list + additional questions All 13 FRCP-EM Program directors Data Analysis Canadian FRCP-EM residents via each program director
Methods: PD survey Each procedure Relative importance (Likert scale) Minimum experience required for competence Intervals: 0, 1-3, 4-6, 7-9, 10-19, 20-29, 30 or more
Methods: Resident survey Each listed procedure Comfort level (5 point Likert scale) Experience Intervals: 0, 1-3, 4-6, 7-9, 10-19, 20-29, 30 or more Additional Questions Impact of ED flow on procedure opportunities Perceived adequacy of residency procedure training Ranking of rotations with highest yield for procedure opportunities
Methods: Analysis Program director survey Procedures ranked at least very important by 70% of PDs Minimum number required to achieve competence for each procedure (70% consensus) Resident survey Descriptive statistics ANOVA: comfort levels and procedural experience Statistical differences between junior & senior residents
Results Program director response rate: 13/13 (100%) Resident response rate: 86/239 (36%)
Program director threshold for competence (by consensus) 1 Electrical defibrillation 4 Anterior pack for epistaxis Corneal foreign body removal Ear/nose foreign body removal I/O insertion Paraphimosis reduction Transcutaneous pacing 7 Arthrocentesis Fracture reduction Chest tube Pericardiocentesis Abscess I&D Crichothyroidotomy Electrical cardioversion Nail procedures Posterior pack for epistaxis Upper airway foreign body removal Joint reduction Regional nerve block
Program director threshold for competence (by consensus) 10 Arterial line insertion Central line insertion (landmark technique) Central line insertion (U/S guided) Lumbar puncture Procedural sedation 20 Adult medical resuscitation Adult trauma resuscitation Adult endotracheal intubation 30 U/S FAST Pediatric medical resuscitation Pediatric trauma resuscitation Pediatric endotracheal intubation
Overall, resident mean comfort scores increased with experience 5 4 Comfort 33 (p<0.0001) 2 1 0 1-3 4-6 7-9 10-19 20-29 >30 Number of times performed
Experience: Procedures never performed by majority (>50%) of residents Procedure 1. Pericardiocentesis 2. Cricothyroidotomy 3. Intraosseus line insertion 4. Posterior pack for epistaxis 5. Paraphimosis reduction 6. Upper airway foreign body removal 7. Pediatric medical resuscitation 8. Pediatric trauma resuscitation PD threshold for competence 1 4 4 4 4 4 20 20
Experience: Procedures never performed by majority (>50%) of senior (PGY4-5) residents Procedure 1. Pericardiocentesis 2. Cricothyroidotomy 3. Intraosseus line insertion 4. Posterior pack for epistaxis 5. Paraphimosis reduction PD threshold for competence 1 4 4 4 4
Procedures rated with a comfort level <4 by majority (>50%) senior residents Procedure 1. Pericardiocentesis 2. Cricothyroidotomy 3. Posterior pack for epistaxis 4. Paraphimosis reduction 5. Pediatric trauma resuscitation PD threshold for competence 1 4 4 4 20
Are residents more likely to report comfort performing a procedure if they achieve the PD consensus threshold for competence? Residents achieved PD threshold Adult Endotracheal Intubation 95% Residents did not achieve PD threshold 45% P<0.05 0 20 40 60 80 % of residents who reported "comfort" Statistically significant for 90% of all important procedures
Are senior residents more likely than junior residents to achieve the PD consensus threshold for competence? Adult medical resuscitation Senior Residents 65% Junior Residents 8% P <0.05 0 20 40 60 80 100 % of residents achieving PD consensus threshold Statistically significant for 78% of procedures
Do residents receive adequate procedural skills training during residency?
Rotations ranked #1 for procedural skill acquisition 50 P = 0.712 40 Response rate (%) n=84 30 20 10 0 ICU Anesthesia Trauma surgery Rotation Orthopedics
Does ED flow affect resident procedural skill opportunities? Neutral 10% Disagree 15% Agree 75% Resident responses, n=86. Proportional agreement did not differ between Jr and Sr residents (p=0.847)
Conclusions List of procedures was established from PD responses regarding procedure importance & frequency for competency Resident self-reported experience is related to self-reported comfort Five procedures have never been performed by >50% of senior EM residents
Conclusions Pediatric procedures had low reported rates of comfort and experience Residents agree they receive adequate procedural training during residency (EM & ICU rotations being most important for procedural skill acquisition) Resident perceptions exist that ED flow impacts their opportunities for procedures
Discussion Minimum experience for competence (defined by PD expert consensus) may be useful for competency-based education criteria Further efforts must be made to ensure residents achieve competence in all important EM procedures prior to completion of residency Infrequent exposure to important procedural skills may necessitate alternative venues for training Our data is of interest to EM educators and program directors in the development of competency-based education and curriculum design
Acknowledgements Dr. Karen Woolfrey Jodi Herold (Wilson Centre) Alex Kiss (ICES)
THANK YOU
Limitations Low response rates Estimates of competence by PDs Recall bias Self-reported estimates of comfort No data regarding specific institutions
Procedural skills training sessions offered in Canadian FRCP- EM residencies 12/13 programs responded (92.3%) Simulation lab: 8 Cadavers: 5 ATLS course: 2 ACLS course: 1 Ultrasound course: 3 Procedure skills teaching sessions: 3
Procedure logs 12/13 programs responded (92.3%) 8/12 do not use procedure logs to track resident procedures 11/12 program directors estimated compliance rates of 60% or less for procedure logs
Procedures considered not important by majority of program directors Thoracotomy Vaginal Delivery Extensor tendon repair Diagnostic peritoneal lavage Gastric lavage Suprapubic bladder catheterization Compartment pressure measurement NG insertion Peripheral venous cutdown Escharotomy Thoracentesis Lateral canthotomy Transvenous pacing Colonoscopy
ROYAL COLLEGE EM PROCEDURE OBJECTIVES Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic and select and perform these medical procedures in an appropriate, safe and skilful manner with due attention to minimizing patient risk and discomfort Possess a detailed knowledge of the indications, contraindications, methods and potential complications of the common medical therapeutic and investigative procedures employed in the practice of and have demonstrated proficiency in the performance of these procedures, either in the clinical setting or through simulation
Competence in Competence No single tool assessment can determine competence Competence is dynamic Definition: degree to which individual can use the knowledge, skills & judgement associated with the profession to perform effectively in the domain of possible encounters defining the scope of professional practice Suggested methods: ITER, logs, simulation Sherbino et al. CJEM 2008
Competence in Competence in procedures Competency refers to a resident s ability to safely prepare for, perform and navigate the complications of a procedure Comfort comfort is likely mitigated by performer characteristics and may not correlate with observed performance Mourad et al. J Gen Int Med 2008
Comparison of PD threshold for competence with resident comfort levels Adult medical resuscitation Adult trauma resuscitation Pediatric trauma resuscitation Central line insertion (U/S guided) Central line insertion (landmark) Procedural sedation Lumbar puncture Abscess I & D PD consensus threshold for competence 20 20 20 10 10 10 10 4 Resident experience required to achieve a level of comfort 4 7 10 7 7 7 7 1