Filling the Void: Defining Invasive Bedside Procedural Competency for Internal Medicine Residents

Abstract

Background Residents perform invasive bedside procedures in most training programs. To date, there is no universal approach for determining competency and ensuring quality and safety of care. Objective We developed and implemented an assessment of central venous catheter insertion competency for internal medicine and internal medicine–pediatrics residents, using measurements for knowledge, skill, and attitude and linking them to procedural outcomes. Methods We conducted a cohort study of a 4-week, resident-run procedure service from July 2007 through June 2011 at a large academic medical center. Knowledge was assessed by using a written test, technical skill by using a checklist, and attitude by self- and supervisor assessments of residents' confidence and capability. Competence was defined as (1) a minimum written test score (70%); (2) a perfect checklist score; (3) a resident's self-assessed confidence and capability scores of 4 or 5 of 5; and (4) faculty rating of the resident's confidence and capability as 5 of 5. A composite success rate was based on procedural outcomes (eg, completed procedures, less than 3 forward needle passes, and complication rate) and was compared to the checklist scores. Results A total of 148 internal medicine and medicine–pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4 weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent. Conclusions Our multi-factorial criteria used to define central venous catheter insertion competency effectively discriminated between residents judged to be competent and those judged not competent, using data from procedural outcomes.

Simulation Improves Procedural Protocol Adherence During Central Venous Catheter Placement

“…Based on data now available from other studies, 6,11 a 40–50% increase in first-pass cannulation would have been more realistic. Our pragmatic trial design also impaired our ability to detect an effect of the intervention 19 since the simulation intervention was less intense than in some 12,27 but not all 15,16,20,30,43 prior studies and guidance by a supervising physician during each procedure may have improved performance and prevented some complications. Overall, insufficient power prevents definitive conclusions regarding simulation’s influence on procedural proficiency and complications.…”

“…Based on prior studies and expert opinion, we defined successful independent CVC placement by (1) vein cannulation on the first or second needle pass combined with (2) 100% adherence to seven key indicators of procedural technique (Table 1, see below). 27 In accordance with principles of mastery learning, 26 intervention subjects who did not meet these criteria during the unassisted simulated CVC placement repeated supervised simulator training and evaluation until they achieved procedural competence based on these criteria. Simulation training occurred during the two weeks prior to their MICU rotation or, when scheduling conflicts arose, as soon as possible following the start of this rotation.…”

Curriculum for the Performance of Ultrasound‐Guided Procedures

“…Checklists can be developed to evaluate the components of the procedure performed. In addition, there should be a scale developed to globally evaluate the performance of the procedure …”

Training Using Simulation in Internal Medicine Residencies: An Educational Perspective

“…A number of various procedures have demonstrated increased confidence and competence in procedures with simulation. [8][9][10] Competence would be defined as determined to be ready for the procedure without direct supervision. One set back is ambulatory procedures such as pap smears and arthrocentesis.…”