Patient Discomfort and Resident Confidence after Intra-Articular Injection Simulation Training: A Randomized Controlled Trial ADAE O. AMOAKO MD, NEHA KAUSHIK.

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Presentation transcript:

Patient Discomfort and Resident Confidence after Intra-Articular Injection Simulation Training: A Randomized Controlled Trial ADAE O. AMOAKO MD, NEHA KAUSHIK MD, TIMOTHY D. RILEY MD1; AND GEORGE G.A. PUJALTE MD2 1Department of Family and Community Medicine, Penn State Hershey Medical Center, Hershey, PA 2Sports Medicine, Divisions of Primary Care, and Orthopedics, Mayo Clinic Health System, Waycross, GA

Disclosures Dr. Pujalte is part-owner of Ridonk, LLC®, a company that develops medical applications (“apps”). Dr. Riley has no disclosures

Background Arthritis and other MSK diseases Over 40 million adults 60 million by 2020 May need intraarticular injections Family physicians expected to know how to perform knee intraarticular injections

Background “The goal of family practice training is to produce fully competent physicians capable of producing high quality care…of which should include procedure skills which are within the scope of family practice.” – ACGME

Background “Family medicine residencies should strive to teach... procedures done by a substantial number of practicing family physicians, both in the ambulatory and inpatient settings” – AAFP

Background Injection workshops and trainings Increased confidence and preparedness in Internal Medicine residents Limited studies in Family Medicine

Purpose of study Does extra simulation training have an effect on the comfort level of Family Medicine residents being trained to do knee injections, and the pain level felt by their patients as they perform the injections?

Study Design Randomized controlled trial Family medicine residents at Penn State Milton S. Hershey Medical Center randomized into two groups Penn State Hershey IRB-approved

Methods The intervention group The control group 2 simulations sessions 1 patient encounter The control group Typical training No model simulation Patients who needed steroid injections anyways Patients consented to take part in study at time of injection Reminders hung in resident and attending work areas with details of study protocol to facilitate obtaining injections Results emailed to investigators

Methods Measured Outcomes Pain level of procedure as described by patient Scale of 1-10 Comfort level of resident Very comfortable Somewhat comfortable Not comfortable Not very comfortable Attending asked patient level of pain after procedure Asked resident level of comfort in doing the procedure

Methods Data Analysis A Wilcoxon Rank Sum test was used in calculating all p-values P < 0.05 was defined as the level of statistical significance Statistical Analysis System (SAS), version 9.3 (SAS Institute Inc.)

Results 29 Residents 3 Didn’t Participate 26 Participated Intervention Control Investigators Opted Out 12 14 2 1

Preliminary Results Intervention group Control group 6 out of 12 patient encounters Control group 7 out of 14 patient encounters

Preliminary results Comfort Level Comparison Comparison of Intervention and Control Group by Residents’ Comfort Level Study group Total (n = 26) Encounters Mean Min Max P-value Intervention 12 6 1.20 1.00 2.00 0.057 Control 14 7 2.13 4.00

Comparison of Intervention and Control Group by Patients’ Pain Level Preliminary results Pain Level Comparison Comparison of Intervention and Control Group by Patients’ Pain Level Study group Total (n = 26) Encounters Mean Min Max P-value Intervention 12 6 1.80 0.00 4.00 0.156 Control 14 7 3.63 1.00 9.00

Limitations of study Small sample size Technique Supervising faculty influence Pilot study, not expecting statistical significance One technique taught on model; attendings may use other techniques during patient care Relationship with faculty, skill of faculty, extent and quality of pre-procedure prep

Preliminary conclusion Residents in the intervention group were more comfortable with the procedure with a difference that approached significance We found a nonsignificant trend toward decreased pain during the procedure for the intervention group

Implication of study Model simulation training may boost residents’ comfort level and reduce patient discomfort during corticosteroid knee injections. Further study with larger sample size is needed to characterize extent of effect Similar research could be considered for steroid injection involving other joints Another avenue for future study could be whether residents with higher level of comfort are more likely to perform the

Acknowledgement Erik Lehman MS Penn State Hershey Department of Public Health Sciences

References Okkes IM, Polderman GO, Fryer GE, et al. The role of family practice in different health care systems: a comparison of reasons for encounter,diagnoses, and interventions in primary care populations in the Netherlands,Japan, Poland, and the United States. J FamPract. 2002; 51:72–73. The American Academy of Family Practice. Procedural Skills. (http://www.aafp.org/about/policies/all/procedural-skills-scope.html) Accessed July, 29, 2013. Hershey, PA: ACGME 2013. Lisa K. Sharp, Ralph Wang, and Martin S. Lipsky. Perception of Competency to Perform Procedures and Future Practice Intent: A National Survey of Family Practice Residents. Acad Med. 2003;78:926 –932. Wigton, RS., Alguire, P. The declining number and variety of procedures done by general internisist: A resurvey of members of the American College of Physicians. Ann Intern Med. 2007; 146:355-360. Jolly, M, Curran JJ. Underuse of intra-articular and peri-articular corticosteroid injections by primary care physicians. J Clin Rheum. 2003 Vol 9;3. Gormley GJ, Corrigan M, et. Al. Joint and soft tissue injections in the community: questionnaire survey of general practitioners’ experiences and attitudes. Ann Rheum Dis 2003;62:61-64.