PROCEDURAL COMPETENCY Dumb Luck, Chance, A Plan

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PROCEDURAL COMPETENCYDumb Luck, Chance, A Plan

• Linda Spillane, MD
• Associate Professor, Emergency Medicine
• University of Rochester

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Dumb Luck

• The resident who hasnt gotten enough chest tubes
  just happens to be on duty when 6 patients are
  shot during a squabble 3 of whom need chest
  tubes.
• The junior attending is able to refrain from
  stepping in to do the procedure himself.

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Chance

• With High Volume, High Acuity, and Enough
  Opportunity the odds are that each resident will
  become competent at performing all procedures.
• Odds improve with a longer LOS, relative lack of
  ICU beds, and the availability of equipment with
  which to do procedures.

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Educational Plan

• Progression
• Animal model, simulator or cadaver
• Controlled setting Real Patients
• ED Real Patients
• Labs and workshops
• Animal
• Cadaver
• Skills Workshops

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Educational Plan

• Rotations
• EM
• Off-Service
• PGY3 Teaching/Admin Rotation
• Bedside Teaching/Supervision
• Simulation
• Cadaver Labs

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Procedural Competency

• By the completion of residency training every
  resident will be competent to perform all
  procedures crucial to the practice of Emergency
  Medicine.
• Importance of various procedures will change
  over time (DPL vs. Ultrasound).
• Expected level of proficiency for individual
  procedures may vary.

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Procedural Competency

• Quantity
• Quality Demonstration of
• Technical Skill
• Knowledge of indications, contraindications and
  complications of procedures
• Accurate interpretation of results of diagnostic
  procedures (DPL, Ultrasound)

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University Of Rochester Plan

• Teaching and assessing procedural competency
• Labs and workshops
• EM rotations
• Off-service rotations
• Tracking procedures
• Forms
• Problems and considerations

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Labs and Workshops
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Orientation

• Simulations (2, 4-hour sessions)
• Basic Principles of Emergency Care
• Defibrillation
• Monitoring Equipment
• Suction
• Traditional courses
• ATLS new trauma simulator
• PALS IO line and pediatric airway lab

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Orientation

• Ultrasound Orientation (16 hours)
• Didactic (8 hours)
• Standardized patients (8 hours)
• Procedural Skills Labs
• Splinting (2 hours)
• Slit Lamp (2 hours)
• Suturing (2, 2-hour pigs feet labs)

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Difficult Airway Workshop

• Yearly, during conference
• Mandatory attendance
• Skills Stations
• Cricothyrotomy Lab (pig trachea)
• LMA/Combitube insertion (mannequins)
• Use of Bag-Valve-Mask/Intubation (mannequins)

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Simulation

• Technical Skills
• Intubation
• Defibrillation/Pacing
• Cricothyrotomy
• Needle Decompression of Chest
• Recognition of need to perform a procedure
• Recognition of complications of procedures

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Cadaver Labs

• Luck
• Too many bodies donated to the medical school
• Chance
• New faculty member
• Loves procedures loves to teach
• Not over-committed

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Cadaver Labs

• Plan
• Semi-annual procedure labs
• DPL
• Cricothyrotomy
• Thorocotomy
• Thorocostomy
• Central Lines
• Targeted dissections
• Anticipatory injury lab

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Emergency Medicine Rotations

• PGY1
• EM rotations
• Emergency Orthopedics
• Ultrasound
• PGY2
• Trauma/Resuscitation Assignment
• PGY3
• Teaching/Administration

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Strategies That Have Worked

• Build a new ED
• Assign residents to different geographic areas
  within the ED
• Change work hours to parallel patient flow

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Strategies That Have Not Worked

• Triaging patients differently by shift or day of
  the week based on resident staffing
• Having the triage nurse or mid-level providers
  identify patients with specific chief complaints
  to be seen by residents

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Emergency Orthopedics

• Residents given a case/procedure list and Tx
  guidelines
• 10 hour shifts (2 pm-12 mid)
• Seek and Find Cases throughout ED
• Paged by PGY3 or attending
• Precepted by ED attending
• Ortho consulted as needed
• Formal presentation at monthly ortho QA
  conference

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Ultrasound

• 2-week ultrasound rotation
• Precepted by EM faculty trained in US
• Residents work 40-50 hours/week
• Perform and document adequate views for 6
  focused exam types
• Images reviewed with credentialed faculty

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Off-Service Rotations

• Procedurally based rotations in PGY1 year
• Learn technical skills in controlled setting
• CT surgery (chest tubes)
• Anesthesia
• Ultrasound
• OB

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Off-Service Rotations

• Progressive responsibility and autonomy in PGY2
  and 3 years
• SICU
• Burn/Trauma ICU
• Trauma Team Rotation

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Competency AssessmentQuantity
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Quantity

• Residents are required to document all procedures
• Compliance varies
• Computerized procedure log is a great tool
• Typical Rotation Experience
• Individual Resident Experience

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Quantity

• Card system entered into access data base
• Lost Cards/Double entry
• Easier to get sign-off by off-service faculty
• Commercial Products
• Web-based/single entry from anywhere
• More cumbersome for faculty
• Products have different attributes
• New Innovations
• GME Toolkit (Data Harbor)

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Exposures

• Track Exposures
• Patients assigned to Resuscitation Room
• Patients admitted to ICUs
• Trauma Registry
• Patients treated and released by chief complaint
• Review of Billing Data

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Competency AssessmentQuality
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Faculty

• EM Rotation Evaluations
• Technical Skills
• Pediatric, Trauma, and Medical Resuscitation
  Skills
• Off-Service Faculty Evaluations
• Technical Skills
• Follow-up on Complications of Procedures

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Problems

• Evaluations not filled out
• Everyone is average to above average
• Very little specific and constructive feedback
  about how to improve

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Self-Assessment

• Review procedure log
• Ask specifically if there are any procedures that
  residents dont feel comfortable with

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Personality and Variation in Accuracy of
Self-Assessment
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Structured Assessment

• Simulations
• Log of scenarios/skills demonstrations
• Formative assessment
• Mock oral boards includes 2 simulated patients
• Formal assessment of airway management and
  defibrillation skills

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Structured Assessment

• Procedure lab faculty credentialing based on
  objective criteria
• Splints
• Suturing
• Cricothyrotomy
• Cadaver Labs faculty credentialing based on
  objective criteria
• Chest tubes
• Thorocotomy
• DPL

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Structured Assessment

• Competency based assessment of skills as a
  criteria for successfully completing a rotation.
• Anesthesia
• Setting up for a controlled intubation
• Use of Bag valve mask
• Intubation
• Appropriate use of sedative/anesthetic agents

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Formal Credentialing Ultrasound

• Pass written exam (80)
• Document 25 adequate focused exams FAST,
  gallbladder, renal, aorta, gyn, cardiac
• Residents and faculty have same credentialing
  standards

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Future Plans

• Structured assessment of procedural skills at the
  bedside
• Faculty
• R3 residents on teaching/admin rotation

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Problems and Considerations

• RRC
• JACHO
• HIPPA

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RRC

• New RRC guidelines suggest numbers of certain
  procedures that the average resident should do
  prior to graduation.
• Target should motivate residents to document
  better.

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JACHO

• Hospital Credentialing JACHO requires hospitals
  to know which residents are credentialed to do
  which procedures without direct supervision.
• Each residency program must have a process by
  which residents are credentialed.
• Usually Quantitative
• Sometimes Qualitative

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HIPPA

• Using patient identifiers on web based systems to
  log procedures may violate HIPPA regulations.
• Faculty will not be able to verify procedural
  competency on-line if no patient identifiers are
  included in requests for verification.