Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees

Abstract

Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions.Objective: Our hypothesis was that over the past decade the rate of procedures performed by Pediatric Critical Care Medicine Fellowship trainees decreased.Methods: Retrospective review at a single institution, tertiary, academic, children's hospital of patients admitted from July 1, 2007–June 30, 2017 to the Pediatric Intensive Care Unit and Cardiothoracic Intensive Care Unit. A Poisson regression model with a scale adjustment for over-dispersion estimated by the square root of Pearson's Chi-Square/DOF was applied.Results: There has been a statistically significant decrease in the average rate of central venous lines (p = 0.004; −5.72; 95% CI: −9.45, −1.82) and arterial lines (p = 0.02; −7.8; 95% CI: −13.90, −1.25) per Fellow per years in Fellowship over the last 10 years. There was no difference in the rate of intubations per Fellow per years in Fellowship (p = 0.27; 1.86; 95% CI:−1.38, 5.24).Conclusions: There has been a statistically significant decrease in the rate of central venous lines and arterial lines performed by Pediatric Critical Care Medicine Fellowship trainees per number of years in Fellowship over the last 10 years. Educators need to be constantly reassessing the clinical landscape in an effort to make sure that trainees are receiving adequate educational experiences as this has the potential for an impact on the education of trainees and the safety of the patients that they care for.

Declining Procedures in Pediatric Critical Care Medicine Using a National Database

“…We believe our study has serious implications for the field of PCCM. There has been a decrease over time in the number procedures performed by residents ( 6 , 7 ) well as by PCCM fellows ( 1 ). We have now demonstrated a decrease over time in procedures per admission for a large cohort of pediatric critical care units in the United States and Canada.…”

“…Pediatric Critical Care Medicine (PCCM) intensivists need initially to learn and subsequently to maintain the skills necessary to provide both airway support and vascular access to critically ill patients. In a recent single-center study, we demonstrated a decline over time in the number of arterial catheter and central venous catheter (CVC) placed by pediatric critical care fellows during their training ( 1 ). It is possible there has been a decline in the rate of procedures performed in PICUs, in general, over time, due to an increase in noninvasive ventilation and use of peripherally inserted central catheters (PICCs).…”

Procedural Competency for Pediatric Residents in the Contemporary Training Environment: An Unachievable Goal?

“…This is a significant decline from previous eras (Leone, Rich and Finer, 2005;Gabrani et al, 2018) with numerous contributing factors, including changes in medical management (Finer et al, 2004;Wyckoff et al, 2015), staffing (Moote et al, 2011;Smith and Hall, 2011), supervision (Gozzo et al, 2011), and workflow (Accreditation Council for Graduate Medical Education, 2017). Previous authors have reported decreased volume for specific procedures (i.e., intubation), but this study demonstrates a decline across all procedures (Gozzo et al, 2011;Engorn et al, 2018). Residents are now infrequently performing procedures on the floor and intensive care units, which may be due to presence of subspecialty fellows or other staff who need to develop proficiency.…”

“…Despite assumptions that trainees would advocate for additional procedural opportunities, their cumulative procedure numbers did not differ, suggesting influence of other factors (competition for procedures by other providers, limited procedural numbers overall, and work-hours restrictions). These residents must rely on fellowship training to master skills, compounding concerns regarding declining procedural opportunities for subspecialty fellows (Gozzo et al, 2011;Mittiga et al, 2013;Engorn et al, 2018).…”

Variation in Arterial and Central Venous Catheter Use in Pediatric Intensive Care Units

“…This is a finding that is consistent with trends published in the literature and suggests that the decline in IC placement cannot be solely explained by decreasing illness acuity. 27 Institutional use of non-invasive technology to monitor and treat patients (such as end tidal carbon dioxide monitoring and ultrasound guided placement of peripheral intravenous catheters) may be associated with decreased need for IC placement. 28,29…”