Dataset Information

Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training.

ABSTRACT: Objectives:Emergency department thoracotomy (EDT) is a rare and challenging procedure. Emergency medicine (EM) residents have limited opportunities to perform the procedure in clinical or educational settings. Standardized, reliable, validated checklists do not exist to evaluate procedural competency. The objectives of this project were twofold: 1) to develop a checklist containing the critical actions for performing an EDT that can be used for future procedural skills training and 2) to evaluate the reliability and validity of the checklist for performing EDT. Methods:After a literature review, a preliminary 22-item checklist was developed and disseminated to experts in EM and trauma surgery. A modified Delphi method was used to revise the checklist. To assess usability of the checklist, EM and trauma surgery faculty and residents were evaluated performing an EDT while inter-rater reliability was calculated with Cohen's kappa. A Student's t-test was used to compare the performance of participants who had or had not performed a thoracotomy in clinical practice. Item-total correlation was calculated for each checklist item to determine discriminatory ability. Results:A final 22-item checklist was developed for EDT. The overall inter-rater reliability was strong (? = 0.84) with individual item agreement ranging from moderate to strong (? = 0.61 to 1.00). Experts (attending physicians and senior residents) performed well on the checklist, achieving an average score of 80% on the checklist. Participants who had performed EDT in clinical practice performed significantly better than those that had not, achieving an average of 80.7% items completed versus 52.3% (p < 0.05). Seventeen of 22 items had an item-total correlation greater than 0.2. Conclusions:A final 22-item consensus-based checklist was developed for the EDT. Overall inter-rater reliability was strong. This checklist can be used in future studies to serve as a foundation for curriculum development around this important procedure.

SUBMITTER: Zaidi HQ

PROVIDER: S-EPMC7163202 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training.

Zaidi Hashim Q HQ Dhake Sarah S SS Miller Danielle T DT Sista Priyanka P Pirotte Matthew J MJ Fant Abra L AL Salzman David H DH

AEM education and training 20190912 2

<h4>Objectives</h4>Emergency department thoracotomy (EDT) is a rare and challenging procedure. Emergency medicine (EM) residents have limited opportunities to perform the procedure in clinical or educational settings. Standardized, reliable, validated checklists do not exist to evaluate procedural competency. The objectives of this project were twofold: 1) to develop a checklist containing the critical actions for performing an EDT that can be used for future procedural skills training and 2) to ...[more]

PMID: 32313860

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Project description:IntroductionEmergency department thoracotomy (EDT) is a lifesaving procedure within the scope of practice of emergency physicians. Because EDT is infrequently performed, emergency medicine (EM) residents lack opportunities to develop procedural competency. There is no current mastery learning curriculum for residents to learn EDT. The purpose of this study was to develop and implement a simulation-based mastery learning curriculum to teach and assess EM residents' performance of the EDT.MethodsWe developed an EDT curriculum using a mastery learning framework. The minimum passing standard (MPS) for a previously developed 22-item checklist was determined using the Mastery Angoff approach. EM residents at a four-year academic EM residency program underwent baseline testing in performing an EDT on a simulation trainer. Performance was scored by two raters using the checklist. Learners then participated in a novel mastery learning EDT curriculum that included an educational video, hands-on instruction, and deliberate practice. After a three-month period, residents then completed initial post testing. Residents who did not meet the minimum passing standard after post testing participated in additional deliberate practice until mastery was obtained. Baseline and post-test scores, and time to completion of the procedure were compared with paired t-tests.ResultsOf 56 eligible EM residents, 54 completed baseline testing. Fifty-two residents completed post-testing until mastery was reached. The minimum passing standard was 91.1%, (21/22 items correct on the checklist). No participants met the MPS at the baseline assessment. After completion of the curriculum, all residents subsequently reached the MPS, with deliberate practice sessions not exceeding 40 minutes. Scores from baseline testing to post-testing significantly improved across all postgraduate years from a mean score of 10.2/22 to 21.4/22 (p <0.001). Mean time to complete the procedure improved from baseline testing (6 minutes [min] and 21 seconds [sec], interquartile range [IQR] = 4 min 54 sec - 7 min 51 sec) to post-testing (5 min 19 seconds, interquartile range 4 min 17sec - 6 min 15 sec; p = 0.001).ConclusionThis simulation-based mastery learning curriculum resulted in all residents performing an EDT at a level that met or exceeded the MPS with an overall decrease in time needed to perform the procedure.

Project description:ObjectivesTemporary transvenous cardiac pacing (TVP) is a potentially lifesaving intervention included in the list of essential core procedures for emergency medicine (EM) training; however, opportunities to perform TVP during residency cannot be guaranteed. EM graduates report feeling subjectively underprepared for this procedure, but objective performance data are lacking. Checklist-based simulated assessment is an increasing focus of competency-based medical education, particularly for invasive procedures like TVP. The objectives of this paper were as follows: first, to enlist a multidisciplinary team of experts to create an assessment tool for TVP using best practices in checklist development; second, to determine the reliability of checklist scoring; and third, to assess EM residents' baseline ability to perform TVP using a dedicated task trainer.MethodsThis study was conducted at a single 4-year EM residency. A panel of emergency physicians and cardiologists designed a TVP checklist using a modified Delphi approach. After consensus was achieved on a final checklist, EM residents were assessed using a dedicated TVP task trainer. Inter-rater reliability was determined using Cohen's kappa coefficient. Resident performance was determined by number of correctly performed checklist items.ResultsThe expert panel achieved consensus on a 30-item checklist after three rounds of revisions. The Cohen's kappa coefficient for the overall checklist score was 0.87, with individual checklist items ranging from 0.63 to 1.00. In total, 58 residents were assessed with a mean score of 13.5 of 30 checklist items. Scores increased with each year of training.ConclusionsThis study details the rigorous development of a TVP checklist designed by a multidisciplinary team of experts. Checklist scores demonstrated strong inter-rater reliability. The overall poor performance of this cohort suggests the current approach to TVP training does not provide sufficient preparation for EM residents. Competency-based techniques, such as simulation-based mastery learning, should be explored.

Project description:Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as it has potential to improve patient-centeredness of checklists related to assessment of clinical performance. Focus group patient participants from 2 clinical sites were included: Thomas Jefferson University Hospital, Philadelphia, PA, and Northwestern University Hospital, Chicago, Illinois.The authors developed a preliminary instrument based on existing checklists, clinical experience, literature review, and input from an expert panel comprising health care professionals and patient advocates. They then refined the instrument based on feedback from 2 waves of patient focus groups, resulting in a final 21-item checklist. The checklist items assess if uncertainty was addressed in each step of the discharge communication, including the following major categories: introduction, test results/ED summary, no/uncertain diagnosis, next steps/follow-up, home care, reasons to return, and general communication skills. Patient input influenced both what items were included and the wording of items in the final checklist. This patient-centered, systematic approach to checklist development is built upon the rigor of the Checklist Development Checklist and provides an illustration of how to integrate patient feedback into the design of assessment tools when appropriate.

Project description:ImportanceProcedural sedation for children undergoing painful procedures is standard practice in emergency departments worldwide. Previous studies of emergency department sedation are limited by their single-center design and are underpowered to identify risk factors for serious adverse events (SAEs), thereby limiting their influence on sedation practice and patient outcomes.ObjectiveTo examine the incidence and risk factors associated with sedation-related SAEs.Design, setting, and participantsThis prospective, multicenter, observational cohort study was conducted in 6 pediatric emergency departments in Canada between July 10, 2010, and February 28, 2015. Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study. Of the 9657 patients eligible for inclusion, 6760 (70.0%) were enrolled and 6295 (65.1%) were included in the final analysis.ExposuresThe primary risk factor was receipt of sedation medication. The secondary risk factors were demographic characteristics, preprocedural medications and fasting status, current or underlying health risks, and procedure type.Main outcomes and measuresFour outcomes were examined: SAEs, significant interventions performed in response to an adverse event, oxygen desaturation, and vomiting.ResultsOf the 6295 children included in this study, 4190 (66.6%) were male and the mean (SD) age was 8.0 (4.6) years. Adverse events occurred in 736 patients (11.7%; 95% CI, 6.4%-16.9%). Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events. There were 69 SAEs (1.1%; 95% CI, 0.5%-1.7%), and 86 patients (1.4%; 95% CI, 0.7%-2.1%) had a significant intervention. Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%]). The incidence of adverse sedation outcomes varied significantly with the type of sedation medication. Compared with ketamine alone, propofol alone (3.7%; odds ratio [OR], 5.6; 95% CI, 2.3-13.1) and the combinations of ketamine and fentanyl citrate (3.2%; OR, 6.5; 95% CI, 2.5-15.2) and ketamine and propofol (2.1%; OR, 4.4; 95% CI, 2.3-8.7) had the highest incidence of SAEs. The combinations of ketamine and fentanyl (4.1%; OR, 4.0; 95% CI, 1.8-8.1) and ketamine and propofol (2.5%; OR, 2.2; 95% CI, 1.2-3.8) had the highest incidence of significant interventions.Conclusions and relevanceThe incidence of adverse sedation outcomes varied significantly with type of sedation medication. Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofol or fentanyl.

Project description:BackgroundAlthough usage and acceptance are important factors for a successful implementation of clinical decision support systems for medication, most studies only concentrate on their design and outcome. Our objective was to comparatively investigate a set of traditional medication safety measures such as medication safety training for physicians, paper-based posters and checklists concerning potential medication problems versus the additional benefit of a computer-assisted medication check. We concentrated on usage, acceptance and suitability of such interventions in a busy emergency department (ED) of a 749 bed acute tertiary care hospital.MethodsA retrospective, qualitative evaluation study was conducted using a field observation and a questionnaire-based survey. Six physicians were observed while treating 20 patient cases; the questionnaire, based on the Technology Acceptance Model 2 (TAM2), has been answered by nine ED physicians.ResultsDuring field observations, we did not observe direct use of any of the implemented interventions for medication safety (paper-based and electronic). Questionnaire results indicated that the electronic medication safety check was the most frequently used intervention, followed by checklist and posters. However, despite their positive attitude, physicians most often stated that they use the interventions in only up to ten percent for subjectively "critical" orders. Main reasons behind the low usage were deficits in ease-of-use and fit to the workflow. The intention to use the interventions was rather high after overcoming these barriers.ConclusionsMethodologically, the study contributes to Technology Acceptance Model (TAM) research in an ED setting and confirms TAM2 as a helpful diagnostic tool in identifying barriers for a successful implementation of medication safety interventions. In our case, identified barriers explaining the low utilization of the implemented medication safety interventions - despite their positive reception - include deficits in accessibility, briefing for the physicians about the interventions, ease-of-use and compatibility to the working environment.

Dataset Information

Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training.

Publications

Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training.

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