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 (j = 0.84) with individual item agreement ranging from moderate to strong (j = 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 itemtotal 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.

Creation and Implementation of a Mastery Learning Curriculum for Emergency Department Thoracotomy

“…These results are similar to our previous study in which a pilot group of general surgery and EM residents and attendings performed an EDT on the simulation trainer and were evaluated with the checklist; those who had not performed an EDT in the clinical environment had lower mean scores on ensuring all instruments were present, maintaining sterility, and gathering equipment. 23 In the pilot study, those who had not performed an EDT in the clinical environment also on average performed worse on all steps involved in controlling cardiac hemorrhage from incising the pericardium, to delivering the heart, to controlling hemorrhage via Foley catheter, suture, or pledgets.…”

“…A MPS for the previously published checklist 23 was established by an expert panel using the mastery Angoff method 24 . A panel of 17 physicians – 15 emergency physicians and two trauma surgeons with experience performing and teaching the procedure – were recruited to serve as judges for the standard-setting process.…”

“…Second was to establish a MPS for a previously developed 22-item checklist for use in this mastery curriculum. 23 Third was to determine whether this mastery learning curriculum could result in achievement of the MPS by all participants. Fourth was to compare baseline and final post-test performance on checklist items and time to perform an EDT in a simulated environment.…”

Using a Simulated Model and Mastery Learning Approach to Teach the Ultrasound‐guided Serratus Anterior Plane Block to Emergency Medicine Residents: A Pilot Study

“…The amount of practice needed to achieve mastery may vary between providers, but the final determination of achieving mastery is uniform. Mastery learning is an effective method of teaching multiple emergency medicine (EM) skills and procedures including paracentesis, 15 lumbar puncture, 16 thoracentesis, 17 central venous catheter insertion, 18,19 and thoracotomy 20 . Mastery learning has also been shown to result in higher first success rates and lower adverse patient safety events such as reduction of catheter‐related bloodstream infections 21 .…”

“…Mastery learning is an effective method of teaching multiple emergency medicine (EM) skills and procedures including paracentesis, 15 lumbar puncture, 16 thoracentesis, 17 central venous catheter insertion, 18,19 and thoracotomy. 20 Mastery learning has also been shown to result in higher first success rates and lower adverse patient safety events such as reduction of catheter-related bloodstream infections. 21 Given the success of mastery learning in teaching other procedures, we thought it appropriate to use a mastery learning approach to teach residents the SAPB.…”