1. 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

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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

13. 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

14. Task Trainers

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

19. Other examples

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

21. 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).

22. 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

23. 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

24. 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

25. Questions?