SIMPLE procedures: Survey of Internal Medicine Providers' Limitations and Experiences with procedures and medical procedure services.

BACKGROUND: In response to a decline in bedside procedures performed by hospitalists, some hospital medicine groups have created medical procedure services (MPSs) concentrating procedures under the expertise of trained hospitalist-proceduralists. OBJECTIVES: To characterize the structure, breadth, and heterogeneity of academic medical center MPSs, as well as compare the procedural landscape for groups with and without an MPS. METHODS: The Survey of Internal Medicine Providers' Limitations and Experiences with Procedures and MPSs, is a cross-sectional study, conducted in the United States and Canada through a web-based survey administered from October 2022 to March 2023. We used convenience and snowball sampling to identify eligible study participants. The survey explored presence of MPS, procedure volumes, patient safety, and educational practices. For MPSs, we explored onboarding, staffing, skill maintenancy, funding, and barriers to growth. RESULTS: Forty instututions (response rate 97.5%), represented by members of the Procedural Research and Innovation for Medical Educators (PRIME) consortum participated in the survey. MPSs were found in 75% of the surveyed institutions. Most MPSs (97%) involved trainees and were staffed by internists (100%) who often had additional clinical duties (70%). The majority (83%) of MPSs used checklists and procedural safety guidelines, but only 53% had a standardized process for tracking complications. There was significant variability in determining procedural competency and supervising trainees. Groups with an MPS reported higher procedure volume compared to those without. CONCLUSIONS: MPSs were highly prevalent among the participating instutitions, offered a broad array of bedside procedures, and often included trainees. There was a high variability in funding models, procedure volumes, patient safety practices, and skill maintenance requirements.

Rethinking the consultation paradigm: Validity evidence for a new framework, a multimethods study.

BACKGROUND: In-hospital consultation is essential for patient care. We previously proposed a framework of seven specific consultation types to classify consult requests to improve communication, workflow, and provider satisfaction. METHODS: This multimethods study's aim was to evaluate the applicability of the consult classification framework to real internal medicine (IM) consults. We sought validity evidence using Kane's validity model with focus groups and classifying consult requests from five IM specialties. Participants attended five 1 h semi-structured focus groups that were recorded, transcribed, and coded for thematic saturation. For each specialty, three specialists and three hospitalists categorized 100 (total 500) random anonymized consult requests. The primary outcome was concordance in the classification of consult requests, defined as the sum of partial concordance and perfect concordance, where respectively 4-5/6 and 6/6 participants classified a consult in the same category. We used χ2 tests to compare concordance rates across specialties and between specialists and hospitalists. RESULTS: Five major themes were identified in the qualitative analysis of the focus groups: (1) consult question, (2) interpersonal interactions, (3) value, (4) miscommunication, (5) consult framework application, barriers, and iterative development. In the quantitative analysis, the overall concordance rate was 88.8% (95% confidence interval [CI]: 85.7-91.4), and perfect concordance was 46.6% (95% CI: 42.2-51.1). Concordance differed significantly between hospitalists and specialists overall (p = .01), with a higher proportion of hospitalists having perfect concordance compared to specialists (67.2% vs. 57.8%, p = .002). CONCLUSIONS: The consult classification framework was found to be applicable to consults from five different IM specialties, and could improve communication and education.

Validation of an Educational Tool for Skin Abscess Incision and Drainage by Delphi and Angoff Methods.

BACKGROUND: Bedside incision and drainage (I&D) of skin abscesses is a common medical procedure performed in a variety of medical settings. Yet, there is a paucity of published validated educational tools to teach and assess competency for this procedure. OBJECTIVE: To validate an educational tool to teach and assess competency for bedside I&D of skin abscesses via the Delphi consensus and Angoff standard setting methods. DESIGN: Expert consensus on the importance of each procedural step in the educational tool was obtained using the Delphi method, consisting of four rounds of iterative revisions based on input from a panel of experts. The passing cut-off score for a proficient provider was determined using the modified dichotomous Angoff method. PARTICIPANTS: All participants met the minimum criteria of active involvement in resident education and performance of at least 20 skin abscess I&D's within the past 5 years. Participant specialties included general surgery, emergency medicine, and internal medicine. MAIN MEASURES: The primary outcome was consensus on procedural steps and errors, defined as an interquartile range ≤ 2 on a 9-point Likert scale. A cut-off score was determined by the average across all respondents for the anticipated number of errors that would be committed by a provider with the level of proficiency defined in the survey. Qualitative input was incorporated into the educational tool. KEY RESULTS: At the end of four rounds of review via the Delphi process, participants achieved consensus on 93% of items on the clinical checklist and 85% of errors on the assessment checklist. Via the modified dichotomous Angoff method, the determined passing cut-off for competency was 6 out of 22 errors. CONCLUSION: An educational and evaluation tool for bedside I&D of skin abscesses was validated via the Delphi and Angoff methods.

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.