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PubMed1998

Some new multiple-test procedures for dose finding.

In Tamhane, Hochberg, and Dunnett (1) we focused primarily on step-down test procedures based on contrasts among the sample means to find the minimum effective dose in a dose-response study. In the present article we use the global tests of Bartholomew (2,3) and Hayter (4) in these step-down procedures. We also propose a new step-down procedure that permits tests based on a class of contrasts [step and basin contrasts of Ruberg (5) are examples of such contrasts] that could not be used with the step-down procedures studied in our previous paper because of lack of control of the familywise error rate. A simulation study to compare the four procedures proposed in the present paper with the top four procedures from the previous article is carried out. It is found that the step-down procedure based on Bartholomew's test and the new step-down procedure based on step and modified basin contrasts generally perform better than the other procedures for a wide range of dose-response profiles.

Algorithms↗
PubMed2004

Comparison of three procedures for initial fitting of compression hearing aids. II. Experienced users, fitted unilaterally.

This paper is the second in a series comparing three procedures for the initial fitting of multichannel compression hearing aids. The first paper reported the results for a group of 10 experienced hearing aid users fitted bilaterally. This paper reports the results for a different group of 10 experienced hearing aid users fitted unilaterally. The three procedures were: (1) CAMEQ, which aims to amplify speech so as to give equal loudness per critical band over the frequency range 500-5000 Hz, and to give similar overall loudness to normal over a wide range of speech levels; (2) CAMREST, which aims to amplify speech so as to restore normal specific loudness patterns, over a wide range of speech levels; and (3) DSL [i/o], which aims to map the dynamic range of normal-hearing people into the reduced dynamic range of hearing-impaired people, with full restoration of audibility. Each subject was fitted with one Danalogic 163D digital hearing aid, using each of the three fitting procedures in turn; the order was counter-balanced across subjects. Prescribed insertion gains for 55 and 80 dB SPL input levels were verified using real-ear measurements. Immediately after fitting with a given procedure, and 1 week after fitting. the gains were adjusted, when required, by the minimum amount necessary to achieve acceptable fittings. On average, the adjustments were smallest for the CAMREST procedure, slightly larger for the CAMEQ procedure, and largest of all for DSL [i/o]. For the DSL [i/o] the gain changes were mostly negative, especially for high frequencies and the higher input level. After these gain adjustments, users wore the aids for at least 3 weeks before speech reception thresholds (SRTs) for sentences in quiet and in steady and fluctuating background noise were measured. The APHAB questionnaire was also administered. The hearing aids were then refitted with the next procedure. SRTs and APHAB scores did not differ significantly between the three procedures. We conclude that the CAMEQ and CAMREST procedures provide a more appropriate initial fitting than DSL [i/o] for unilaterally experienced hearing aid wearers. Comparison with our earlier study based on bilateral fittings suggests that the preferred gains are similar for unilateral and bilateral fittings.

Acoustic Stimulation↗
PubMed2006

Procedure-specific surgical site infection rates and postdischarge surveillance in Scotland.

OBJECTIVE: To investigate the impact of postdischarge surveillance (PDS) on surgical-site infection (SSI) rates for selected surgical procedures in acute care hospitals in Scotland. DESIGN: Prospective surveillance of SSI after selected surgical procedures. SETTING: The Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP), which is based on the methodology of the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance system (NNIS). Thirty-two of 46 acute care hospitals throughout Scotland contributed data to SSHAIP for this study. METHODS: Data were from 21,710 operations that took place between April 1, 2002, and June 30, 2004; nine categories of surgical procedures were analyzed. CDC NNIS system definitions and methods were used for SSI PDS. PDS is a voluntary component of the mandatory SSI surveillance program in Scotland. PDS was categorized as none, passive, active without direct observation, and active with direct observation. RESULTS: From our study information, PDS data were available for 12,885 operations (59%). A total of 2,793 procedures (13%) were associated with passive PDS and 10,092 (46%) with active PDS. The SSI rate among the 8,825 operations with no PDS was 2.61% (95% confidence interval [CI], 2.3%-3.0%), which was significantly lower than the SSI rate found among the 12,885 operations for which PDS was performed (6.34% [95% CI, 5.9%-6.8%]). For breast surgery, cesarean section, hip replacement, and abdominal hysterectomy, the rate of SSI when PDS was performed was significantly higher than that when PDS was not performed (P<.01 for each procedure). No differences in SSI rates were found for surgery to repair fractured neck of the femur or for knee replacement. SSI rates were examined according to procedure type, performance of PDS, and NNIS risk index; rates of SSI increased with NNIS risk index within procedure group and PDS group. Logistic regression analyses confirmed that procedure type, performance of PDS, and NNIS risk index were all statistically independent predictors of report of an SSI (P<.05). CONCLUSIONS: This Scottish national data set incorporates a substantial amount of PDS data. We recommend a procedure-specific approach to PDS, with direct observation of patients after breast surgery, cesarean section, and hysterectomy, for which the length of stay is typically short. Readmission surveillance may be adequate to detect most SSIs after orthopedic surgery or vascular surgery, for which the length of stay is typically longer.

Cohort Studies↗
PubMed1994

Radiofrequency ablation of accessory pathways: implications of accumulated experience and time dedicated to procedures.

Previous reports on radiofrequency ablation of accessory pathways have shown that the experience of the operator is of crucial importance in reducing fluoroscopy time and achieving higher success rates. However, a detailed analysis of this important issue has not been previously attempted. We analysed 71 consecutive ablation procedures undertaken at St George's Hospital by the same electrophysiology group and always with the same first operator. Of all procedures, 66 (91.6%) were successful, as judged by abolition of accessory pathway conduction without recurrence within the next 24 h. Failures included two out of 38 left-sided pathway procedures (5.3%), one out of 11 intermediate septal (9.1%) and four out of 22 right-sided pathway procedures (18.2%). These differences were not statistically significant. Average procedure and screening times for all procedures were 162.9 +/- 86.0 min and 56.8 +/- 48.2 min respectively, whereas the median of the number of discharges was 12, ranging from one to 51. There was no significant difference between pathway groups or between concealed and non-concealed pathways in respect to procedure and screening time or number of discharges. There was a significant tendency towards decreased procedure and screening times with accumulating experience and this was similar for all pathway groups. There was also a tendency towards improved cumulative success rates with time dedicated to procedures. We conclude that a certain amount of ablation experience is required, even by experienced electrophysiologists, before a relatively high success rate without long radiation exposure can be achieved, regardless of the location or the mode of conduction of the pathway.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1987

Soleus muscle electromyographic activity and ankle dorsiflexion range of motion during four stretching procedures.

Volitional muscle contractions are used frequently in some combination with muscle stretching to promote muscle relaxation and to increase range of motion. In this study, muscle lengthening procedures were evaluated in the ankle plantar flexors. Four soleus muscle stretching procedures--static stretch (SS), hold relax (HR) (isometric plantar flexor contraction before stretch), agonist contract (AC) (dorsiflexor contraction assisting stretch), and hold relax-agonist contraction (HR-AC)--were performed in the sagittal plane by 12 physically active adults. The dorsiflexion angle, soleus muscle electromyogram, and soleus muscle motoneuron excitability as determined by the Hoffmann-reflex (H-reflex) amplitude were measured throughout the duration of each stretch. The range of dorsiflexion achieved at the end of the stretch did not differ significantly between stretching procedures, although in 8 of the 12 subjects and in the subject group as a whole, the AC and HR-AC procedures were associated with higher levels of soleus muscle EMG than the levels in the SS and HR procedures (p less than .01). The H-reflex amplitudes during the AC and HR-AC procedures were smaller than the amplitudes during the SS and HR procedures (p less than .001), suggesting the possibility of reciprocal inhibition during the agonist contraction. Increased tonic EMG levels produced by input from other neural pathways affecting alpha motoneurons in the AC and HR-AC procedures may have masked this inhibitory reflex. In healthy adults, a complicated procedure, involving muscle contractions for decreasing active resistance to stretch, may be unnecessary because active resistance to stretch is minimal and muscle relaxation during stretch appears to have little or no direct effect on the ROM achieved.

Adult↗
PubMed2002

The construction of learning curves for basic skills in anesthetic procedures: an application for the cumulative sum method.

UNLABELLED: This study aimed at constructing learning curves for basic procedural skills in anesthesiology using the cumulative sum method. We recorded 1234 peripheral venous cannulations, 895 orotracheal intubations, 688 spinals, and 344 epidurals performed by residents during the first 10 mo of training. Learning curves for each procedure were constructed by using the cusum method. The number of procedures performed until attainment of acceptable failure rates was calculated. All residents mastered peripheral venous cannulation after 79 +/- 47 procedures. Four of 7 residents attained acceptable failure rates at orotracheal intubation after 43 +/- 33 proce- dures. Seven of 11 residents attained acceptable failure rates at spinal anesthesia after 36 +/- 20 procedures. At epidural anesthesia, 5 of 11 residents attained acceptable failure rates after 21 +/- 11 procedures. The cusum method is a useful tool for objectively measuring performance during the learning phase of basic procedures. The wide interindividual variability in the number of procedures required to be performed before attaining acceptable failure rates suggests that performance should be followed on an individual basis. IMPLICATIONS: Learning curves for peripheral venous cannulation, tracheal intubation, and spinal and epidural anesthesia were constructed using the cumulative sum (cusum) method. There was a wide variability in the number of procedures performed until attainment of acceptable failure rates. The cusum method may improve our means of evaluating residents' technical skills.

Anesthesia, Epidural↗
PubMed2003

Perception of competency to perform procedures and future practice intent: a national survey of family practice residents.

PURPOSE: A national survey of family practice (FP) chief residents to identify the type of procedural skills they have completed, assess their perceptions of competence to perform those procedures, and identify the procedures they anticipate performing in practice. METHOD: A questionnaire asking about training and competency in 31 core procedures for family medicine (FM) was developed from the literature and pilot tested on residency directors for face validity and clarity. The questionnaires were mailed to chief residents at the 463 FM residency programs in the United States between July and October 2001. RESULTS: A total of 265 (57%) questionnaires were returned. Ninety-six percent of respondents were PGY3 seconds, and 40% were women. All residents had performed excision of a lesion, drainage of an abscess, and simple suturing. Residents were least likely to have performed vasectomy (46%), thoracotomy (41%), and rigid sigmoidoscopy (34%). The mean number of procedures performed during residency and the number of procedures the resident intended to perform in practice differed by gender. Residents who planned to practice in rural areas anticipated performing more procedures than did those who planned to practice in suburban areas (20 versus 17; p >/=.001). Over 90% of residents felt competent to perform obstetrics, but fewer than 50% planned to in practice. CONCLUSION: Despite reports that core procedural skills are taught, this study suggests significant numbers of residents are not being taught certain procedures in a manner that results in residents feeling competent to perform them.

Clinical Competence↗
PubMed2004

U.S. and Canadian internal medicine clerkship directors' opinions about teaching procedural and interpretive skills to medical students.

PURPOSE: Although medical students gain experience in performing procedures during their clinical clerkships, which skills they should acquire remains unclear. The authors sought opinions from internal medicine clerkship directors regarding procedural and interpretive skills students should and do learn during clerkships. METHOD: In 2002, the 123 members of the Clerkship Directors in Internal Medicine (CDIM) were confidentially surveyed using a 79-item questionnaire about the appropriateness of 20 procedural skills, demographics, clerkship characteristics, and curricula in procedural skills. Participants had the choice of completing a mailed paper questionnaire or an electronic version on the CDIM's Web site. After univariate analysis, adjusted comparisons among participants were made using linear regression. RESULTS: Surveys were completed by 89 clerkship directors (72%). Most thought that students should be taught 17 of 20 procedural skills. However, the majority thought students do not learn five of these skills. Over 80% of respondents thought students should learn: chest x-ray interpretation, electrocardiogram interpretation, phlebotomy, throat culture, blood culture, urinalysis, Pap smear, central line placement, peripheral blood smear. However, the majority thought students do not learn five of these skills. The mean of skills that should be taught and are learned were 15 (standard deviation [SD] = 3) and 12 (SD = 4), respectively. About half used formal teaching in procedures (44%), used logs (51%) and tested competency (45%). CONCLUSIONS: CDIM members thought medical students should be taught a variety of procedural skills but thought students fail to learn many. These findings may help prioritize which procedures to teach. It may be helpful to develop standardized curricular materials on teaching procedures.

Adult↗
PubMed1994

Fiberoptic bronchoscopy in the intensive care unit--a prospective study of 147 procedures in 107 patients.

OBJECTIVE: To determine the value and safety of fiberoptic bronchoscopy in an intensive care unit (ICU). DESIGN: Prospective survey. SETTING: ICUs at a tertiary care hospital (except for seven procedures that were performed at a peripheral hospital ICU). PATIENTS: A total of 107 patients with a mean age of 43.9 yrs (range 15 to 84). INTERVENTIONS: One hundred forty-seven fiberoptic bronchoscopy procedures (116 performed on patients who were undergoing mechanical ventilation) were performed on 107 patients. Ninety-four procedures were for diagnostic reasons (upper and lower airway inspection, focal and diffuse pulmonary infiltrates), 37 for therapeutic reasons (bronchial toilet, pulmonary hemorrhage, endotracheal intubation), and 16 for both reasons. Topical anaesthesia was used for fiberoptic bronchoscopy; sedation was rarely needed. Appropriate diagnostic and therapeutic procedures were performed. MEASUREMENTS AND MAIN RESULTS: Oxygen saturation, electrocardiogram, and blood pressure were monitored. Transbronchial biopsies (all on mechanical ventilation) for diffuse pulmonary infiltrates were diagnostic in five of seven cases, and were suggestive of the diagnosis in a further case. Endobronchial biopsies were not diagnostic in any of three cases. Bronchial brushings for microbiology were positive in nine of 50 procedures and for cytology in one of nine procedures. Protected specimen brushes for pulmonary infiltrates gave positive microbiology findings in five of 23 procedures. In pulmonary hemorrhage, focal bleeding was found in five cases, diffuse bleeding in four, and no bleeding source in three. In lobar atelectasis, bronchial toilet led to full reexpansion (n = 20 procedures), partial reexpansion (n = 5), and no change (n = 3). Intubation with fiberoptic bronchoscopy was successful in four of five patients. Hypoxemia (oxygen saturation < 90%) occurred in 29 procedures; it caused no problems. Complications included hemorrhage (n = 2), supraventricular tachycardia (n = 1), pneumothorax (n = 1), pneumatocele (n = 1), and bronchospasm (n = 1). No deaths were attributable to fiberoptic bronchoscopy. CONCLUSIONS: Fiberoptic bronchoscopy in the ICU is safe, contributes valuable diagnostic information, and is useful for therapeutic purposes.

Adolescent↗
PubMedDate not supplied

MR-guided procedures using contemporaneous imaging frameless stereotaxis in an open-configuration system.

Frameless MR-guided procedures have had limited application using conventional closed magnets, due largely to the technical difficulties involved. As a result of in-room MR image-monitoring capabilities, new open-design magnets now allow frameless stereotaxis using contemporaneous imaging to guide more invasive procedures. We evaluate our clinical experience with this new technique. An open-design 0.2 T magnet (Siemens OPEN) combined with an in-room monitor was used for 33 frameless MR-guided procedures (aspiration cytology, biopsy, and/or treatment) in a variety of locations in the head, neck, spine, brain, pelvis, and abdomen. Success of the procedure was based on the ability to accurately position the instrument in the target region to allow biopsy and/or treatment. The open-design magnet allowed the physician to directly access the patient for frameless stereotaxis as the procedure was performed. The in-room monitor provided contemporaneous imaging feedback during the procedure for successful placement of the instrument in the target region. Twenty-eight biopsy and five treatment procedures were performed. In all cases the technique resulted in successful placement of the instrument within the target tissue to complete the procedure. MR-guided procedures using contemporaneous imaging frameless stereotaxis are possible in an open-design magnet with in-room image monitoring and offer exciting possibilities for further development.

Adolescent↗
PubMed1997

Effect of relaxation music on patient tolerance of gastrointestinal endoscopic procedures.

The use of relaxation music as an adjunct to sedation has not been well studied. We tried to determine whether the use of relaxation music can improve patient tolerance of gastrointestinal endoscopic procedures. Fifty-nine patients undergoing gastrointestinal endoscopic procedures were randomly assigned to receive either relaxation music (n = 28) or no music (n = 31) using headphones and a portable compact disc player. Patient anxiety before the procedure, tolerance of the procedure, and willingness to undergo a repeated procedure were self-assessed using a visual analog scale. Patient tolerance was also assessed by the assisting nurse. There was no significant difference in the overall tolerance score between the two groups. However, a significantly higher proportion of patients described the experience of a gastrointestinal endoscopic procedure as being at least moderately unpleasant in the no-music group. Patient acceptance of the relaxation music was high: 82% in the group stated they would have music again if they required another procedure. We conclude that, even in patients who have sedation, relaxation music can reduce the number who find the experience of gastrointestinal endoscopic procedures unpleasant. Therefore we believe it has a role as an adjunct to sedation in gastrointestinal endoscopic procedures.

Endoscopy, Gastrointestinal↗
PubMed1993

Medicare beneficiaries: adverse outcomes after hospitalization for eight procedures.

Rehospitalization following surgery is widely recognized as an important outcome measure. The purpose of this study was to identify rehospitalizations for adverse events following 8 procedures, using diagnosis and procedure codes contained in Medicare claims files. Adverse events were broadly defined as: 1) complications; 2) failure of the procedure to achieve its therapeutic goal; and 3) untoward events associated with the natural history of the disease being treated with the procedure. Expert panels identified specific diagnosis and procedure codes that might indicate an adverse event if they appeared on the Medicare record of a rehospitalization. Among patients undergoing percutaneous transluminal coronary angioplasty, almost 36% were rehospitalized for an adverse event within a year of surgery; among patients undergoing coronary artery bypass graft surgery, 20% were rehospitalized for an adverse event. Following the other 6 procedures (cholecystectomy, partial excision of the large intestine, total knee replacement, total hip replacement, replacement of the head of the femur, and reduction of fracture of the femur) between 4% and 9% of patients were rehospitalized for an adverse event. Findings from this exploratory study indicate that rehospitalizations for adverse events appear to be a useful outcome measure for the cardiac procedures; they appear to be less useful for the other procedures, at least at the individual hospital or small area level, because of their relative rarity. Future studies should investigate procedures associated with more frequent rehospitalizations, and medical admissions, which often tend to be associated with higher rehospitalization levels.

Aged↗
PubMed1996

A study of two procedures of HIV-1 isolation from whole blood cultures.

Culture techniques for isolation of HIV-1 from small amounts of whole blood (WB) treated with anticoagulant have been reported and gave results identical to those of culture of separated peripheral blood mononuclear cells. Some authors obtained much higher isolation rates when EDTA was used instead of heparin. We compared two previously described techniques for cultivation of HIV-1 from WB of adult HIV+ patients staged according to the CDC classification. In addition, we assessed the influence of the type of anticoagulant used for the collection of blood in viral replication in cell cultures from whole blood. Small volumes of WB treated with either heparin or EDTA were cocultivated with phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PHA-PBMC) from healthy donors. We used two procedures for WB culture: procedure I, based on the culture of 250 microliters of WB with 1 x 10(6) PHA-PBMC from donors; and procedure II based on the culture of 500 microliters of WB with 4 x 10(6) PHA-PBMC from donors. The cocultures were placed in 24-well plates and incubated for as long as 28 days in medium containing interleukin 2 (IL-2). Twice weekly half of the medium was replaced with fresh medium. In procedure II, one million fresh PHA-PBMC from donors was added on the 7th day of culture. The culture supernatant was assayed for the presence of HIV-1 p24 antigen in an enzyme immunoassay. The kinetics of HIV-1 replication in cultures of WB from 7 AIDS patients were similar using procedures I and II. In 8 HIV+ patients the isolation rate was higher with heparin- than with EDTA-treated samples. The isolation rate was higher in AIDS patients (n = 8) than in others with both methods. In stage IV patients without AIDS (n = 8) we failed to isolate HIV-1 in 1 patient with procedure I, whereas we succeeded with procedure II. In stage II, HIV-I was isolated in 1 of 4 patients with both methods. HIV was isolated in cultures of WB from patients receiving zidovudine or related nucleoside analogues and in cultures of WB from untreated patients. HIV-1 could not be isolated from WB of patients with more than 400 CD4+ T lymphocytes in their peripheral blood (n = 4); however, it was isolated from 14 of 16 patients with less than 400 CD4+ T lymphocytes. Our results suggest that procedure II is more sensitive than procedure I and that heparin is better than EDTA for collecting WB. We showed that the rate of HIV-1 isolation from WB increased in advanced-stage patients. Further studies are needed to define the clinical applications of WB culture.

Acquired Immunodeficiency Syndrome↗
PubMed1986

Medical student training in the performance of diagnostic laboratory procedures.

A study was conducted to determine what diagnostic laboratory procedures medical students recalled being taught during pre-clerkship training, how well they felt they could perform these procedures on entrance to and exit from their clerkship year, and the estimate of frequency of personal performance during the clerkship year. Surveys were mailed to 223 graduating senior students of a medical school. They were asked to supply data regarding 15 pre-selected procedures. In only seven cases did a majority of students recall being taught a procedure. Higher percentages of students who trained at health science centres and a Veterans Administration hospital recalled being taught procedures compared to students who trained at community hospitals. In general, students who performed their pre-clerkship training at the health science centres rated their ability to perform procedures without assistance on entrance to the clerkship year higher than the other two groups. Students who performed at least one half of their clerkships at a health science centre rated their ability to perform procedures without assistance at the termination of their clerkship year higher than those who performed a majority of clerkships at community hospitals. The former group also reported a higher frequency of performance of the procedures than the community hospital group. Most of the procedures for all groups, however, were performed at a rate of less than one/month.

Chicago↗
PubMed2006

Concepts of transtibial amputation: Burgess technique versus modified Brückner procedure.

The technique of a long posterior myocutaneous flap described by Ernest M. Burgess in the late 1960s is one of the most frequent procedures for below-knee amputations worldwide. To account for some potential problems associated with this procedure in patients with occlusive arterial disease, Lutz Brückner developed a modified amputation technique for transtibial amputation in the 1980s. Although this new standardized procedure has been widely used in Germany, it is not well known outside central Europe, secondary to its lack of description in English published work. In this review article, we describe a comparison of the technical aspects of the Burgess procedure with the modified Brückner technique for transtibial amputations. In addition, the charts of 69 consecutive patients with end-stage occlusive arterial disease undergoing below-knee amputation by either of the two standardized procedures (Burgess, n = 29; Brückner, n = 40) were reviewed. The clinical results of the two procedures are reported and compared. Review of the German published work suggests that the two techniques for transtibial amputation in patients with occlusive arterial disease appear to have similar results. This is further supported by data from our own 10-year experience with 69 patients undergoing below-knee amputation by either of the two standardized procedures. This suggests that the Brückner technique is at least equivalent to the Burgess procedure with regard to the clinical outcome in patients with occlusive arterial disease. The potential advantages of the standardized modified Brückner procedure compared with the 'classical' Burgess technique for transtibial amputation remain to be assessed in prospective multicentre trials.

Amputation, Surgical↗
PubMed2005

Increase in procedures performed at dermatology office visits from 1995 to 2001.

BACKGROUND: Over the past few decades, dermatologists have expanded the scope of their practice to include many surgical and cosmetic procedures in response to the development and demand for new procedures. OBJECTIVE: To examine the trend from 1995 in the proportion of dermatology visits associated with procedures to determine if there has been an increase in the number of procedures performed. METHODS: Data from the National Ambulatory Medical Care Survey were used to look at the proportion and types of dermatology visits associated with procedures performed during the years 1995 to 2001. RESULTS: There has been a progressive increase in the number of dermatology visits with procedures, occurring in 29.8% of visits in 1995 and 40.0% of visits in 2001. The top procedures performed are that of excision and destruction, including cryotherapy, electrodesiccation and curettage, and biopsies. CONCLUSION: The number of dermatology visits associated with procedures has increased since 1995. With the numerous new procedures and techniques that have emerged and continue to develop in our field, we expect that dermatologists will continue to be providers of medical, as well as surgical, care for the skin.

Ambulatory Care↗
PubMedDate not supplied

Evaluation of an emergency-procedure teaching laboratory for the development of proficiency in tube thoracostomy.

OBJECTIVE: Emergency-procedure laboratories are not a standardized part of the curriculum for emergency medicine residency programs. The authors evaluated the efficacy of an emergency-procedure laboratory to teach medical students and residents the performance of tube thoracostomy. METHODS: A prospective repeated-measures study of tube thoracostomy placement training was performed in an animal-laboratory setting. Participants were six first-postgraduate-year emergency medicine residents and six fourth-year medical students. Each participant was given a written pretest on tube thoracostomies followed by lectures on tube thoracostomy, venous cutdown, peritoneal lavage, and surgical airway. The procedure laboratory, using an anesthetized canine model (20-25 kg), was then conducted. Tube thoracostomies were timed from skin incision to passage of the tube into the thoracic cavity with subsequent tube fogging. Four attempts per participant were documented. Eighteen days later, an identical procedure laboratory was conducted for the same students including a written posttest identical to the pretest. RESULTS: The written test scores improved for every participant (p < 0.0001). Mean times for procedures completion improved from 121 sec to 39 sec (p = 0<.001) during the first session and improved from 58 sec to 28 sec (p = 0.005) during the second session. Retention of skills was indicated by significant shortening of the time to completion from the first attempt of the first session to that of the second session (121 sec to 58 sec, p = 0.002). CONCLUSION: This procedure laboratory, which emphasized skill repetition, led to improvement in procedural speed and retention of tube thoracostomy skills over time. This approach to teaching clinical procedures should be considered for emergency medicine residency programs and for continuing medical education courses that emphasize acquisition of clinical procedural skills.

Animals↗
PubMed2001

Redefining emergency medicine procedures: Canadian competence and frequency survey.

OBJECTIVE: To redefine the Royal College of Physicians and Surgeons (RCPS) procedural skills list for Canadian emergency medicine (EM) residents through a national survey of EM specialists to determine procedural performance frequency and self-assessment of competence. METHODS: The survey instrument was developed in three phases: 1) an EM program directors survey identified inappropriate or dated procedures, endorsing 127 skills; 2) a search of EM literature added 98 skills; and 3) an expert panel designed the survey instrument and finalized a list of 150 skills. The survey instrument measured the frequency of procedure performance or supervision, self-reported competence (yes/no), and endorsement of one of four training levels for each skill: undergraduate (UG), postgraduate (PG), knowledge only, or unnecessary (i.e., too infrequently performed to maintain competence). RESULTS: All 289 Canadian EM specialists were surveyed by mail; 231 (80%) responded, 221 completed surveys, and 10 were inactive. More than 60% reported competence in 125 (83%) procedures, and 55 procedures were performed at least three times a year. The mean competence score was 121 (SD +/- 17.7, median = 122) procedures. Competence score correlation with patient volume was r = 0.16 (p = 0.02) and with hours worked was r = 0.19 (p = 0.01). Competence score was not associated with year or route (residency vs grandfather) of certification. Each procedure was assigned to a training level using response consensus and decision rules (UG: 1%; PG: 82%; unnecessary: 17%). CONCLUSIONS: A survey of EM clinicians reporting competence and frequency of skill performance defined 127 procedural skills appropriate for Canadian RCPS postgraduate training and EM certification.

Attitude of Health Personnel↗