Bedside Training Research Articles

102 Pocket-size hand-held cardiac ultrasound in the hands of students and junior doctors: does it improve diagnostic accuracy over history, physical examination and ECG?

BackgroundEven though patient history taking and physical examination remain the foundations of patient evaluation in daily clinical practise, there has been a decline in the accuracy of the later. Pocket...

Impact of a Delirium Screening Tool and Multifaceted Education on Nurses’ Knowledge of Delirium and Ability to Evaluate It Correctly

The impact of using a validated delirium screening tool and different levels of education on surgical-trauma intensive care unit (STICU) nurses' knowledge about delirium is unclear. To measure the impact of using the Intensive Care Delirium Screening Checklist (ICDSC), with or without a multi-faceted education program, on STICU nurses' knowledge and perceptions of delirium and their ability to evaluate it correctly. The knowledge and perceptions of subject nurses about delirium, and agreement between the independent assessments of delirium by the subject nurse and by a validated judge (who always used the ICDSC), were compared across 3 phases. Phase 1: No delirium screening tool and no education. Phase 2: ICDSC and minimal education (ie, ICDSC validation study only). Phase 3: ICDSC and multifaceted education (ie, pharmacist-led didactic lecture, Web-based module, and nurse-led bedside training). Nurses' knowledge (mean [SD] score out of 10 points) was similar (P = .08) in phase 1 (6.1 [1.4]) and phase 2 (6.5 [1.4]) but was greater (P = .001) in phase 3 (8.2 [1.4]). Agreement between nurses and the validated judge in the assessment of delirium increased from phase 1 (κ = 0.40) to phase 2 (κ = 0.62) to phase 3 (κ = 0.74). Nurses perceived use of the ICDSC as improving their ability to recognize delirium. Use of a multifaceted education program improves both nurses' knowledge about delirium and their perceptions about its recognition. Implementation of the ICDSC improves the ability of STICU nurses to evaluate delirium correctly.

Low-Dose, High-Frequency CPR Training Improves Skill Retention of In-Hospital Pediatric Providers

To investigate the effectiveness of brief bedside cardiopulmonary resuscitation (CPR) training to improve the skill retention of hospital-based pediatric providers. We hypothesized that a low-dose, high-frequency training program (booster training) would improve CPR skill retention. CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated arrest. Basic life support-certified, hospital-based providers were randomly assigned to 1 of 4 study arms: (1) instructor-only training; (2) automated defibrillator feedback only; (3) instructor training combined with automated feedback; and (4) control (no structured training). Each session (time: 0, 1, 3, and 6 months after training) consisted of a pretraining evaluation (60 seconds), booster training (120 seconds), and a posttraining evaluation (60 seconds). Excellent CPR was defined as chest compression (CC) depth ≥ one-third anterior-posterior chest depth, rate ≥90 and ≤120 CC per minute, ≤20% of CCs with incomplete release (>2500 g), and no flow fraction ≤ 0.30. Eighty-nine providers were randomly assigned; 74 (83%) completed all sessions. Retention of CPR skills was 2.3 times (95% confidence interval [CI]: 1.1-4.5; P=.02) more likely after 2 trainings and 2.9 times (95% CI: 1.4-6.2; P=.005) more likely after 3 trainings. The automated defibrillator feedback only group had lower retention rates compared with the instructor-only training group (odds ratio: 0.41 [95% CI: 0.17-0.97]; P = .043). Brief bedside booster CPR training improves CPR skill retention. Our data reveal that instructor-led training improves retention compared with automated feedback training alone. Future studies should investigate whether bedside training improves CPR quality during actual pediatric arrests.

“Booster” training: Evaluation of instructor-led bedside cardiopulmonary resuscitation skill training and automated corrective feedback to improve cardiopulmonary resuscitation compliance of Pediatric Basic Life Support providers during simulated cardiac arrest*

To investigate the effectiveness of brief bedside "booster" cardiopulmonary resuscitation (CPR) training to improve CPR guideline compliance of hospital-based pediatric providers. Prospective, randomized trial. General pediatric wards at Children's Hospital of Philadelphia. Sixty-nine Basic Life Support-certified hospital-based providers. CPR recording/feedback defibrillators were used to evaluate CPR quality during simulated pediatric arrest. After a 60-sec pretraining CPR evaluation, subjects were randomly assigned to one of three instructional/feedback methods to be used during CPR booster training sessions. All sessions (training/CPR manikin practice) were of equal duration (2 mins) and differed only in the method of corrective feedback given to participants during the session. The study arms were as follows: 1) instructor-only training; 2) automated defibrillator feedback only; and 3) instructor training combined with automated feedback. Before instruction, 57% of the care providers performed compressions within guideline rate recommendations (rate >90 min(-1) and <120 min(-1)); 71% met minimum depth targets (depth, >38 mm); and 36% met overall CPR compliance (rate and depth within targets). After instruction, guideline compliance improved (instructor-only training: rate 52% to 87% [p .01], and overall CPR compliance, 43% to 78% [p < .02]; automated feedback only: rate, 70% to 96% [p = .02], depth, 61% to 100% [p < .01], and overall CPR compliance, 35% to 96% [p < .01]; and instructor training combined with automated feedback: rate 48% to 100% [p < .01], depth, 78% to 100% [p < .02], and overall CPR compliance, 30% to 100% [p < .01]). Before booster CPR instruction, most certified Pediatric Basic Life Support providers did not perform guideline-compliant CPR. After a brief bedside training, CPR quality improved irrespective of training content (instructor vs. automated feedback). Future studies should investigate bedside training to improve CPR quality during actual pediatric cardiac arrests.

Vital Sign Monitoring Using Human Patient Simulators at Pharmacy Schools in Japan

To develop, implement, and assess an experience-based education program using human patient simulators to instruct pharmacy students in monitoring vital signs to identify drug treatment effects and adverse events. Medical emergency care programs using human patient simulators were prepared and facilitated practical clinical training in resuscitation, which required selecting drugs while monitoring changes in blood pressure, pulse, and arterial blood oxygen saturation. Training encompassed the monitoring of routes of drug administration, drawing of simulated blood, vital-sign monitoring based on a pharmaceutical universal training model, vital-sign monitoring devices and simulators, and medical emergency education using biological simulators. Before and after bedside training, students were asked to complete a questionnaire to assess their understanding of vital sign monitoring and emergency care. Students successfully learned how to monitor routes of drug administration, vital signs, and pathological conditions. There was a significant increase in students' recognition of the importance of vital-sign monitoring. Experienced-based training using patient simulators successfully prepared pharmacy students to monitor vitals signs and identify drug treatment effects and adverse events.

A Survey of Student Pharmacists' Attitudes toward New Procedures Expected for Future Pharmacists

Bedsides conventional bedside training the Department of Pharmacy of Kyushu University of Health and Welfare covers advanced practices focused on new procedures expected for future pharmacists. A questionnaire survey was conducted among the 4th year students of the 6-year curriculum of the department in order to retrospectively evaluate their attitudes toward basic life support, and the necessity and feasibility of items related to the training. Sixty-nine percent of the students responded that they would provide appropriate treatment under a situation where basic life support was needed. The item regarded as most necessary and feasible before training was "treatment for basic life support--cardiopulmonary resuscitation." After training, however, "checking vital signs," "physical assessment," and "pharmacist's assistance in medication" were the items rated as equal to or higher than "treatment for basic life support--cardiopulmonary resuscitation." The lowest ranked item in terms of necessity and feasibility both before and after training was "intramuscular/subcutaneous injection," followed by "intravenous injection" and "normal intravenous collection of blood" in that order. The results of this attitude survey demonstrated that many students were willing to perform such operations as part of checking vital signs and physical assessment.

Charting of observations and modified early warning score in a high risk obstetric ward

IntroductionIn the UK, the confidential enquiry into maternal death recommended that a modified early warning score (MEWS) should be used for all obstetric admissions to improve early recognition of sick...

Life-support Training to Improve the Clinical Competence of Pharmacy Students

Life-support (particularly, advanced life-support) training is not included in pharmacist education; however, the life-support should be mastered since a pharmacist is a medical professional. We consider it to be important to master other skills before the life-support practicing, because a pharmacist does not check a patient to assess their clinical condition and administer drugs (suppository, intravenous injection etc.) The pharmacist prepares medicines, but does not administer medicines to treat the patient. Furthermore, the pharmacist is not interested in the vital signs of the patient receiving the medicines (the pharmacist has not identified the patient has complaint from changes in vital signs), which is why pharmacists can not develop themselves as medical professionals. Based on this observation, life-support training should be considered. In other words, to foster pharmacists with high clinical competence, pharmacy students should receive life-support training after training in drug administration and vital sign checks in a bedside training room. Drug administration using a pharmacy system versatile-type training model and pharmacy training model, vital signs check and auscultation using a physical assessment model and a cardiac disease disorder simulator in our bedside practice are useful for advanced life-support using a high-performance care simulator (monitoring vital signs, adrenalin administration and oxygen inhalation for ventricular fibrillation (VF). These training skills can improve the clinical competence of pharmacy students.

Hospitalist use of hand‐carried ultrasound: Preparing for battle

Hand-carried ultrasound (HCU) is a burgeoning technology at a critical point in its development as a general diagnostic technique. Despite the known safety and accuracy of ultrasound in radiology and echocardiography, the use of HCU to augment physical diagnosis by all physicians has yet unrealized potential. In order to incorporate ultrasound into a diagnostic model of routine bedside application, simple imaging and training protocols must first be derived and validated. Simplified cardiac ultrasound exams have already been validated to detect evidence-based targets such as subclinical atherosclerosis, heart failure, and elevated central venous pressures. However, for general examination of the acutely ill patient, it is the internist-hospitalist who should derive a full-body ultrasound examination, balancing training requirements with the numerous clinical applications potentially available. As the hospital's leading diagnostician with ultrasound expertise available in-house, the hospitalist could develop HCU so as to triage and refer more appropriately and limit unnecessary testing and hospital stays. Active involvement by hospitalists now in the planning of outcome, validation, and training studies, will be invaluable in the formation of an "ultrasound-assisted" physical examination in the future and will promote competent, cost-effective applications of HCU within general medical practice.

Training auscultatory skills: computer simulated heart sounds or additional bedside training? A randomized trial on third-year medical students

BackgroundThe present study compares the value of additional use of computer simulated heart sounds, to conventional bedside auscultation training, on the cardiac auscultation skills of 3rd year medical students at Oslo University Medical School.MethodsIn addition to their usual curriculum courses, groups of seven students each were randomized to receive four hours of additional auscultation training either employing a computer simulator system or adding on more conventional bedside training. Cardiac auscultation skills were afterwards tested using live patients. Each student gave a written description of the auscultation findings in four selected patients, and was rewarded from 0-10 points for each patient. Differences between the two study groups were evaluated using student's t-test.ResultsAt the auscultation test no significant difference in mean score was found between the students who had used additional computer based sound simulation compared to additional bedside training.ConclusionsStudents at an early stage of their cardiology training demonstrated equal performance of cardiac auscultation whether they had received an additional short auscultation course based on computer simulated training, or had had additional bedside training.

Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training

The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency. To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training. Multinational, multicenter, single-blind, randomized, controlled trial. Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands. This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts. Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets. Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups. Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices. Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice.

Effect of ERCP Mechanical Simulator (EMS) Practice on Traineesʼ ERCP Performance in the Early Learning Period: U.S. Multi-Center Randomized Controlled Trial 2009 ACG/Governorʼs Award for Excellence in Clinical Research

Purpose: The effect of ERCP mechanical simulator (EMS) practice on trainee performance is unknown. We test the hypothesis that trainees offered EMS practice in addition to routine training (study group-SG) will demonstrate improved clinical outcomes compared to those undergoing routine training only (control group-CG). Methods: 16 fellows engaged in ERCP training from 6 U.S. centers were included. Randomization was stratified by center to avoid bias created by center-specific differences. 8 fellows randomized to SG received didactic teaching on ERCP techniques and 2 sessions (2 months apart) of hands-on EMS practice on selective cannulation (GIE 2007; 65:1056-62). 8 fellows randomized to CG received didactic teaching but no EMS practice. Both groups underwent routine clinical bedside training at respective centers and their clinical ERCP performances were monitored for the first 16 weeks of the academic year using documentation sheets. ERCPs supervised by JWL (EMS instructor) were excluded. Primary outcome was successful biliary cannulation defined as achievement of biliary cannulation with <3 hands-on assistance from supervising endoscopists without getting the scope taken away and performed within the given time frame of 10 minutes. Each hands-on assistance was provided only after 2 failed attempts. Intervention effects were assessed by chi-square test and in multivariable regression models using generalizing estimating equations (GEE) to account for cluster randomization of fellows. Secondary outcomes were cannulation time and trainee competency score graded by supervising physicians blinded to randomization. Results: See table. Cannulation success rate was 47% for CG and 68% for SG (p=0.0006, χ2 test). GEE analysis also showed statistical significance in favor of EMS practice (p=0.034) with higher odds of successful cannulation (adjusted odds ratio=2.6). SG fellows achieved faster cannulation time (278±252 sec vs. 620±846 sec, p<0.001). There was no statistical difference in the trainee competency scores given by supervising physicians, confirming that they were adequately blinded to the randomization, lowering the likelihood that one group was given preferential guidance that might have altered the outcome measures.TableConclusion: In a prospective multi-center RCT during early learning period, a significantly higher proportion of the biliary cannulations performed by trainees who participated in EMS practice in addition to routine training were successful and with faster cannulation time compared to those performed by trainees who only received routine training. The results of this study provide objective evidence for the first time to support the use of EMS practice to augment routine clinical training. Disclosure: Dr Joseph Leung is the inventor of the mechanical simulator and a strong advocate of simulator practice for trainees as a supplement to the traditional clinical training.

Medical Emergency Education Using Emergency Care Simulators in the School of Pharmaceutical Sciences

Clinical pharmacy training III (bedside training) in the School of Pharmaceutical Sciences, Kyushu University of Health and Welfare is intended to train pharmacists who can also cope with medical emergencies. Therefore we produced original scenarios that provide experience of various medical emergencies using emergency care simulators. As a result, these simulators enabled students to experience dealing with various medical emergencies such as cardiopulmonary resuscitation, automated external defibrillation (AED), adrenalin administration, and oxygen inhalation. In addition, a survey on the necessity for and the degree of the understanding of training contents associated with emergency care simulators was performed before and at the end of clinical training. After clinical training, the necessity for and the degree of the understanding of these training contents significantly increased (p<0.01). The introduction of emergency care simulators into clinical pharmacy training provides experience of not only cardiopulmonary resuscitation but also the treatment procedures as well as observation of improvement in the pathological condition after drug administration, which increases pharmacists' awareness of patient needs in drug therapy. Therefore these simulators are helpful for pharmacy education aiming at improving pharmacists' pharmaceutical care ability.

Prospective randomized study on the use of a computer‐based endoscopic simulator for training in esophagogastroduodenoscopy

Computer-based endoscopic simulators have been developed in recent years, and their usefulness has been reported. However, there is no blinded prospective randomized controlled study on esophagogastroduodenoscopy (EGD) training using virtual reality simulators. The present study aimed to assess the effectiveness of a computer-based simulator for basic training in EGD. The GI-Mentor II simulator was used. The subjects were 20 hospital medical residents. After receiving an explanation regarding the fundamentals of endoscopy, 10 trainees were each randomized into a simulator group and a non-simulator group. The simulator group received 5 h of training with the GI-Mentor II plus bedside training, while the non-simulator group received bedside training. Subsequently, each subject performed endoscopy twice for assessment. Performance was evaluated according to a five-grade scale for a total of 11 items. The score was significantly higher in the skills required for insertion into the esophagus, passing from the esophagogastric junction (EGJ) to the antrum, passing through the pylorus, and examination of the duodenal bulb and the fornix. The performance of endoscopy was improved by 5 h of simulator training. The simulator was more effective with regard to the items related to manipulation skills. Computer-based simulator training in EGD is useful for beginners.

Five key principles of a successful clinical research career in infectious diseases

Many talented physicians enter fellowship training in infectious diseases with the ambition to pursue an academic career that includes investigation. Although many embark on laboratory research projects during their research training years, our experience is that most are drawn toward clinical research. For these physicians with extensive bedside training, clinical research has the immediate appeal of clinical relevance. It is often perceived as a natural extension of their expertise. However, as their training ensues, physicians quickly realize the complexity involved in garnering the essentials to success: continued didactic training, securing research funding, publishing results, and most importantly, adjusting to the relatively slow pace of achievement. Additional hurdles for the clinical investigator include learning the process of protocol review by institutional review boards and developing close collaborative relationships with data collectors, data managers, data analysts, and biostatisticians. Without proper mentorship and preparation, many talented individuals become despondent, feel inadequate, and search for alternative career paths. For many young investigators, it is not clear how to develop such a career and avoid common pitfalls. Based on our combined experiences as mentees and mentors, we have outlined fi ve key principles to a successful career in infectious diseases clinical research.

Should simulator use become mandatory in endoscopy training?

Should simulator use become mandatory in endoscopy training?

Diagnostic des fièvres prolongées inexpliquées : tactiques et stratégies

Purpose Diagnosis of fever of unknown origin (FUO) is a major challenge for internists, as emphasized by the high rate of diagnostic failure, despite the fast-moving progress in medical technology. Numerous clues are available in clinical and standard biological data; a better use of the available tests is warranted. Key points Improvement in diagnostic accuracy might be expected by developing strategies targeted toward a more systematic search of diagnosis clues. Intuition and the hypothetic – deductive method that are the most common clinical strategies are the most perfectible. It implies to enjoy the fun of clinical examination, to have a large experience in bedside training, to be confident in his/her own semiological skills, to refer frequently to heuristics, and to use carefully Occam's razor principle. Laboratory tests might be revisited; immunological and serological tests are of little value; standard biological tests provide many insufficiently exploited clues. Imaging procedures depend on objectives: whole body CT scan should be performed early within the first days of hospitalisation, preceded by standard chest radiograph and abdomen ultrasonography; followed by either indium-111 or technetium-99m, labelled leukocytes if deep abscesses are suspected or 18-FDG PET scan in the case of suspected inflammatory disease involving tissues, lymph nodes or arteries. Early identification of the best tissue to be the site of biopsy is one of the most decisive procedures. Conclusion Strategies and tactical approaches for the diagnosis of FUO might be driven by the search of significant clues. Self-clinical experience driven by a wide bedside training is of major concern. Standard laboratory tests might be better used and the choice of imaging depends on objectives. Identification of the most appropriate tissue to be sampled for histological examination is one of the most beneficial step.

薬学部臨床薬学系実習におけるさまざまなバイタルサインを取り入れた教育法の構築

In clinical pharmacy training III (bedside training) at the School of Pharmaceutical Sciences,Kyushu University of Health and Welfare,we included vital sign confirmation using vital sign measuring instruments,physical assessment models for this purpose,ACLS trainers,and high-fidelity patient simulators.Students were able to confirm vital signs (such as blood pressure,pulse rate,respiratory rate,and body temperature) afterwards,and on conducting a survey on students’ opinions of the necessity of vital sign confirmation in training and their level of understanding of it,we observed significant increases in scores as regards both necessity and understanding (p <0.01).The measurement of vital signs by pharmacists is important to evaluating drug efficacy and adverse effects and this type of practical training should greatly contribute to pharmacist education and enhancing their skills.

209: A Survey of Ultrasound Use by Emergency Physicians in California

The use of ultrasound in the practice of emergency medicine has grown dramatically over the last two decades. Published surveys have established the prevalence of bedside ultrasound use, training requirements, and incorporation of quality assurance measures at academic emergency medicine programs. Only one study has attempted to assess the use of ultrasound outside of academic emergency medicine centers. The results of this study, however, may be biased by a low (61%) survey response rate. In our study we sought to determine the current status of emergency physician-performed bedside ultrasound at both academic and community centers in the state of California.

Jordan Palliative Care Initiative: A WHO Demonstration Project

A model for pain relief and palliative care for the Middle East has been established in Jordan. King Hussein Cancer Centre (KHCC) in Amman is now a truly comprehensive cancer center as it includes palliative care for inpatients, outpatients, and patients at home. This is especially important in a country and a region where over 75% of the cancer patients are incurable when diagnosed. To support effective palliative care delivery, there have been many significant changes in Jordan between 2001 and 2006. Regulations governing opioid prescribing have been changed to facilitate effective pain management. The national opioid quota has been increased. Cost-effective, generic, immediate-release morphine tablets are being produced in Jordan. Intensive, interactive bedside training courses for doctors, nurses, and clinical pharmacologists have started to overcome opiophobia and motivate health care professionals to take up palliative care as a profession. “Champions” for palliative care have emerged who are leading the development of palliative care in Jordan's health care systems and starting to support neighboring countries to develop pain relief and palliative care. While before 2003, fewer than 250 patients per year received palliative care, by 2006 more than 800 patients per year were receiving pain relief and palliative care through the KHCC and Al Basheer Hospital. The achieved changes and the unusually rapid and effective institutionalization of palliative care serve as a model for other countries in the Middle East region as to what should be done and how.