A Foundation for Procedure Acquisition and Competence using On-Line Resources, Individualized Education, and Simulation Beth Anne Fox, MD, MPH Jason Moore, MD Janice Schweitzer, MD STFM April, 2011

We have no conflicts of interest to report. Declarations We have no conflicts of interest to report.

Outline Welcome, background, and objectives Participant sharing experiences in procedure supervision and evaluation Overview of rationale for our program Review outcomes of our approach Residents and faculty perceptions Small group discussion of other methods Large group debriefing Summary and future ideas

Objectives Describe the utilization of task-trainers and simulation as a foundation for procedural competence in Family Medicine Discuss the benefits and limitations of simulation procedural training Describe other methods of procedural training and difficulties with determination of competence List three concerns or questions regarding implementation of simulation procedural training in other programs

Background ACGME requires resident acquisition and competence in procedural skills Family Medicine educators directed to provide graduated experiences Residents must reach competence necessary for independent practice by completion of training

Methods of Procedural Training “See one, do one, teach one” Reading only Video review, maybe First patient needing procedure Others?

Clinical Simulation Curriculum Emphasis on Critical Care, Obstetrical, Neonatal and Procedural Skills Low volume, high-risk Providing forum for emphasis on communication, cultural competency, medical ethics, and resident teaching skills Competency based teaching and evaluation

Examples PGY 1: Procedural training ACS; Respiratory Failure Postpartum Hemorrhage and neonatal respiratory depression; Anaphylaxis PGY 2: Rapid Atrial Fib; PE DKA; TCA Overdose Shoulder dystocia; Neonatal meconium aspiration PGY3: Pediatric asthma; Cocaine-induced SVT and ischemia Neonatal sepsis; Pneumothorax Adult sepsis; Hemorrhagic shock

Schedule Outline Two half-day sessions Alternate half-day for each session Even distribution of 19 residents 10-11 each half day One faculty or senior resident at each station

Procedural Simulation Training Session On-line instructional documents and procedural videos NEJM procedure videos Pre- and Post-tests Program evaluation Half-day sessions Hands-on experience with task trainers and mannequins Individualized training by FM faculty and senior residents Procedure competency foundation

Stations Airway management and O2 LP IO, IV, Art line/ABG Urgent/Emergent Diagnostic/Therapeutic Airway management and O2 LP IO, IV, Art line/ABG Chest tube insertion Central Line insertion Circumcision (Gomco) Paracentesis Thoracentesis Nasolaryngoscopy Prostate exam; Breast and pelvic exam

Emergent procedural skills: Oxygen delivery systems Nasal cannula Ventimasks Non-rebreathing mask BiPap Ventilator (initial management) Bag-valve-mask ventilation Intubation Rapid sequence intubation Lumbar puncture Normal adult Pediatric Intravenous line placement Intraosseous line placement Arterial puncture and line placement Chest tube placement Central line placement

Task Trainers

Diagnostic and therapeutic procedural skills: Pelvic exam Breast exam Prostate exam Circumcision Paracentesis Thoracentesis Nasolaryngoscopy

Other examples

Small Groups Methods of assessment? How do you document competence? Evaluation tools? Limit performance?

Initial Results Question Range Mean Std. Dev. 1. I feel well prepared to perform most office based procedures 2-4 3.00 .471 2. I currently feel well prepared to perform most hospital and clinic procedures 2.79 .631 4. I found the e-learning website (D2L) easy to navigate 1-4 2.29 1.139 5. I found the videos and reading assignments helpful in preparing for the HPS sessions 2.50 1.286 6. I feel better prepared to perform procedures after completing the HPS procedures sessions* 3-4 3.41 .507 7. Opportunities are currently available for practicing required procedures .535 10. Simulators are effective tools to learn procedures 3.37 .597 11. Practicing on simulators will help me perform procedures on actual patients more competently 12. I would like more opportunities to use simulators to practice procedures .761 13. I understand the necessary steps for competency for each individual procedure 3.16 .375 14. I would like the opportunity to observe the performance of a procedure unfamiliar to me 3.68 .478 15. I would be interested in having procedure demonstrations/information readily available online 3.58 16. I have adequate opportunities to demonstrate proficiency in procedures to my attendings 2.68 .671 17. My attendings provide me with adequate feedback regarding procedural competency 3.11 .567 18. I would like the opportunity to document procedural competency 3.26 .562 *Participants scored Q6 significantly higher than both Q1 (t(16)=2.75, p=.014) and Q2 (t(16)=4.40, p<.001).

Results, cont. 8. Describe the most likely location you gain practice in performing procedure N Percent of Cases* Sim Lab 5 29.4 Daily Duties On Call 6 35.3 ER 9 52.9 *Adds up to more than 100% because participants could choose multiple answers. 9. What is the greatest obstacle preventing you from performing procedures during residency? N Percent Time 3 15.8 Lack of patients 6 31.6 Lack of experience 10 52.6

Breast exam – 4 Circumcision – 4 Lumbar puncture – 4 List any of the procedures offered during this session that you have already performed as a medical student or resident: Pelvic/pap – 10 Arterial line – 5 Central line – 5 Intubation – 5 IV – 5 Paracentesis – 5 Rectal exam – 5 Breast exam – 4 Circumcision – 4 Lumbar puncture – 4 Bag ventilation – 3 Chest tube – 3 Arterial blood gas – 1 Nasolaryngoscopy – 1

Summary Benefits Limitations Detailed focus on how to perform procedures from multiple media Method of learning procedures when patient population is lacking Method of preparation to perform procedures Build confidence Patient safety Initial session Problems accessing electronic modules and videos Not yet validated Varying skills of participants and prior exposure Checklists incomplete Cost

Questions?