Teaching and Assessing Bedside Procedures: A Standardized Cross-Disciplinary Framework for Graduate Medical Education.

ABSTRACT: Performing bedside procedures requires knowledge, reasoning, physical adeptness, and self-confidence; however, no consensus on a specific, comprehensive strategy for bedside procedure training and implementation is available. Bedside procedure training and credentialing processes across large institutions may vary among departments and specialties, leading to variable standards, creating an environment that lacks consistent accountability, and making quality improvement difficult. In this Scholarly Perspective, the authors describe a standardized bedside procedure training and certification process for graduate medical education with a common, institution-wide educational framework for teaching and assessing the following 7 important bedside procedures: paracentesis; thoracentesis; central venous catheterization; arterial catheterization; bladder catheterization or Foley catheterization; lumbar puncture; and nasogastric, orogastric, and nasoenteric tube placement. The proposed framework is a 4-stage process that includes 1 preparatory learning stage with simulation practice for knowledge acquisition and 3 clinical stages to guide learners from low-risk to high-risk practice and from high to low supervision. The pilot rollout took place at Henry Ford Hospital from December 2020 to July 2021 for 165 residents in the emergency medicine and/or internal medicine residency programs. The program was fully implemented institution-wide in July 2021. Assessment strategies encompass critical action checklists to confirm procedural understanding and a global rating scale to measure performance quality. A major aim of the bedside procedure training and certification was to standardize assessments so that physician trainers from multiple specialties could train, assess, and supervise any participating trainee, regardless of discipline. The authors list considerations revealed from the pilot rollout regarding electronic tracking systems and several benefits and implementation challenges to establishing institution-wide standards. The proposed framework was assembled by a multidisciplinary physician task force and will assist other institutions in adopting best approaches for training physicians in performing these critically important and difficult-to-perform procedures.

Endotracheal Intubation in Patients Treated for Prehospital Status Epilepticus.

INTRODUCTION: Limited data describe the frequency, timing, or indications for endotracheal intubation (ETI) in patients with status epilepticus. A better understanding of the characteristics of patients with status epilepticus requiring airway interventions could inform clinical care. We sought to characterize ETI use in patients with prehospital status epilepticus. METHODS: This study was a secondary analysis of the Rapid Anticonvulsant Medication Prior to Arrival Trial, a multi-center, randomized trial comparing intravenous lorazepam to intramuscular midazolam for prehospital status epilepticus treatment. Subjects received ETI in the prehospital, Emergency Department (ED), or inpatient setting at the discretion of caregivers. RESULTS: Of 1023 enrollments, 218 (21 %) received ETI. 204 (93.6 %) of the ETIs were performed in the hospital and 14 (6.4 %) in the prehospital setting. Intubated patients were older (52 vs 41 years, p < 0.001), and men underwent ETI more than women (26 vs 21 %, p = 0.047). Patients with ongoing seizures on ED arrival had a higher rate of ETI (32 vs 16 %, p < 0.001), as did those who received rescue anti-seizure medication (29 vs 20 %, p = 0.004). Mortality was higher for intubated patients (7 vs 0.4 %, p < 0.001). Most ETI (n = 133, 62 %) occurred early (prior to or within 30 min after ED arrival), and late ETI was associated with higher mortality (14 vs 3 %, p = 0.002) than early ETI. CONCLUSIONS: ETI is common in patients with status epilepticus, particularly among the elderly or those with refractory seizures. Any ETI and late ETI are both associated with higher mortality.

Emergency medicine resident clinical hours: a national survey.

BACKGROUND: Emergency medicine (EM) residency programs have significant scheduling flexibility. As a result, there is potentially significant variation in scheduling practices. Few studies have previously sought to describe this variation. It is unknown how this affects training time in the emergency department. OBJECTIVES: The purpose of this study was to describe the current variation in clinical training practices through clinical hour, shift length, and rotation survey data. METHODS: A 21-item questionnaire was distributed to all allopathic EM training programs utilizing an online survey during the 2011-2012 academic year. Questions included demographic data, number of EM rotations per year, shifts, average hours, shift length, and scheduling practices. RESULTS: A total of 122 responses were received and 82 programs were analyzed (51.6% of 159 allopathic programs). EM residents work, on average, 45.50 h per week. Postgraduate year 1-3 programs utilizing 28-day schedules averaged two additional EM rotations and 338.2 more clinical EM hours compared with calendar-month rotations. The residents of 4-year programs work approximately 1300 additional hours during residency, with an average of 1279.26 h and 7.9 clinical EM rotations in the fourth year. Clinical hour ranges of 2670-5112 and 4248-6113 were observed for 3-year and 4-year programs, respectively. CONCLUSIONS: There are different scheduling modalities used to create resident schedules. This flexibility results in a large amount of diversity in scheduling practices, with certain patterns allowing for significantly more clinical time. This may result in a vastly different training experience for EM residents.