Invasive Bedside Procedures Research Articles

Postoperative Imaging Findings Associated with Transpalpebral Craniotomy Approach to Anterior Cranial Fossa.

Background and Purpose The transpalpebral "eyelid" approach is a novel alternative to the traditional ciliary or supraciliary incision for supraorbital frontal craniotomy and access to the anterior cranial fossa. Though a prior publication from our institution has described the surgical approach in detail along with cosmetic and clinical outcomes, postoperative imaging findings have not yet been described. As this surgical technique becomes more widely practiced, it is essential for neuroradiologists, oculoplastic surgeons, and skull base neurosurgeons to be familiar with the expected postoperative imaging findings, especially those that prompt subsequent intervention. Materials and Methods A retrospective, institutional review board approved review was performed of 102 patients who underwent transpalpebral surgical approach at Allegheny General Hospital from June 2007 through May 2015. Operative reports, pathology reports, preoperative imaging, postoperative imaging, and postoperative clinical documentation were reviewed. Results Forty-nine percent of patients had solely benign expected postoperative imaging findings, 37% had various atypical findings not requiring further intervention (most commonly asymmetric globe protrusion and bone cement in a paranasal sinus), 6% had findings prompting minimally invasive bedside procedures (most commonly pseudomeningocele), and 8% had findings requiring surgical intervention. Conclusion The majority of imaging following the transpalpebral approach showed typical, benign findings, such as minimal pneumocephalus and asymmetric globe protrusion. Nonetheless, members of the clinical team should be aware of the small number of findings requiring intervention, especially pseudomeningocele.

Physician's perspective on point-of-care ultrasound: Experience at a tertiary care emergency department in Qatar

Background: Point-of-care ultrasound (POCUS) is an invaluable tool in the diagnosis and management of conditions presenting to emergency departments across the world. It has also improved the success rate of invasive bedside procedures. Objectives: This study aimed to investigate the current utilization of POCUS in a large tertiary care emergency department in the Middle East and to identify barriers to its utilization. Methods: A cross-sectional survey of emergency physicians' experience with ultrasound was conducted, which included examining the training, exposure, and barriers to use. This paper-based survey was completed by the participants in the presence of the authors of this study to improve compliance. Data were collected over a period of two months, from October to November 2014. Results: A total of 105 physicians participated in the survey. Of these participants, 56 had undergone prior training in ultrasonography by successfully completing courses approved by the Royal College of Emergency Medicine in the United Kingdom, and the Royal College of Physicians and Surgeons of Canada. Twenty-two physicians had completed other non-accredited ultrasound courses. An improvement in ultrasound procedural skills was reported by all those who completed training. A perceived lack of time in the emergency department was the main barrier to scanning patients. Other shortcomings included a deficiency of trained personnel for guidance, shortage of equipment, and a lack of experience and interest among physicians. Hands-on training was considered the preferred method among physicians for enhancing ultrasonography skills. Conclusions: The study identified an underutilization of POCUS by emergency physicians. Availability of dedicated time, equipment, supervision, and training may help to increase its usage.

Physician's perspective on point-of-care ultrasound: Experience at a tertiary care emergency department in Qatar

Background: Point-of-care ultrasound is an invaluable tool in the diagnosis and management of many conditions presenting to emergency departments across the world. It has also improved the success rate of invasive bedside procedures. Objectives: This study aimed to investigate the current utilization of point of care ultrasound in a large tertiary care emergency department in the Middle East and to identify barriers to its utilization. Methods: A cross sectional survey of emergency physician's experience with ultrasound was conducted, examining training, exposure and barriers to use. This paper-based survey was completed by the participants in the presence of study authors to improve compliance. Data was collected over a period of two months, from October to November 2014. Results: One hundred and five (105) physicians participated in the survey. Fifty-six physicians had prior training in ultrasonography from courses approved by The Royal College of Emergency Medicine in the United Kingdom, and The Royal College of Physicians and Surgeons of Canada. Twenty-two physicians had undertaken other non-accredited ultrasound courses. All of them reported an improvement in their procedural skills by employing ultrasound. Perceived lack of time in the Emergency Department was the main barrier to scanning. Other hurdles included a deficiency of trained personnel for guidance, shortage of equipment and a lack of experience and interest. Hands on training were stated as the preferred method for enhancing ultrasonography skills. Conclusions: There has been underutilization of point-of-care ultrasound by emergency physicians. Availability of dedicated time, equipment, supervision and training will help to increase its usage.

Examining Invasive Bedside Procedure Performance at an Academic Medical Center.

Explore the performance patterns of invasive bedside procedures at an academic medical center, evaluate whether patient characteristics predict referral, and examine procedure outcomes. This was a prospective, observational, and retrospective chart review of adults admitted to a general medicine service who had a paracentesis, thoracentesis, or lumbar puncture between February 22, 2013 and February 21, 2014. Of a total of 399 procedures, 335 (84%) were referred to a service other than the primary team for completion. Patient characteristics did not predict referral status. Complication rates were low overall and did not differ, either by referral status or location of procedure. Model-based results showed a 41% increase in the average length of time until procedure completion for those referred to the hospital procedure service or radiology (7.9 vs 5.8 hours; P < 0.05) or done in radiology instead of at the bedside (9.0 vs 5.8 hours; P < 0.001). The average procedure cost increased 38% ($1489.70 vs $1023.30; P < 0.001) for referred procedures and 56% ($1625.77 vs $1150.98; P < 0.001) for radiology-performed procedures. Although referral often is the easier option, our study shows its shortcomings, specifically pertaining to cost and time until completion. Procedure performance remains an important skill for residents and hospitalists to learn and use as a part of patient care.

Let Them In: Family Presence during Intensive Care Unit Procedures.

Families have for decades advocated for full access to intensive care units (ICUs) and meaningful partnership with clinicians, resulting in gradual improvements in family access and collaboration with ICU clinicians. Despite such advances, family members in adult ICUs are still commonly asked to leave the patient's room during invasive bedside procedures, regardless of whether the patient would prefer family to be present. Physicians may be resistant to having family members at the bedside due to concerns about trainee education, medicolegal implications, possible effects on the technical quality of procedures due to distractions, and procedural sterility. Limited evidence from parallel settings does not support these concerns. Family presence during ICU procedures, when the patient and family member both desire it, fulfills the mandates of patient-centered care. We anticipate that such inclusion will increase family engagement, improve patient and family satisfaction, and may, on the basis of studies of open visitation, pediatric ICU experience, and family presence during cardiopulmonary resuscitation, decrease psychological distress in patients and family members. We believe these goals can be achieved without compromising the quality of patient care, increasing provider burden significantly, or increasing risks of litigation. In this article, we weigh current evidence, consider historical objections to family presence at ICU procedures, and report our clinical experience with the practice. An outline for implementing family procedural presence in the ICU is also presented.

Procedural instruction in invasive bedside procedures: a systematic review and meta-analysis of effective teaching approaches

ImportanceOptimal approaches to teaching bedside procedures are unknown.ObjectiveTo identify effective instructional approaches in procedural training.Data sourcesWe searched PubMed, EMBASE, Web of Science and Cochrane Library through December 2014.Study selectionWe included...

Factors influencing resident performance of invasive bedside procedures

In the United States, with changes to resident work hour rules and internal medicine residency procedure requirements, residents are no longer required to perform specific procedures as part of their training. Despite this change, residents continue to encounter patients needing procedures. No study has yet to quantify the amount of procedures residents encounter with the number performed. In our study, we explored internal medicine residents' decision making regarding the performance and referral of invasive bedside procedures, as well as objectively reviewed residents' procedure performance patterns.

Ultrasound-Guided Central Venous Access Using Google Glass

BackgroundThe use of ultrasound during invasive bedside procedures is quickly becoming the standard of care. Ultrasound machine placement during procedures often requires the practitioner to turn their head during the procedure to view the screen. Such turning has been implicated in unintentional hand movements in novices. Google Glass is a head-mounted computer with a specialized screen capable of projecting images and video into the view of the wearer. Such technology may help decrease unintentional hand movements. ObjectiveOur aim was to evaluate whether or not medical practitioners at various levels of training could use Google Glass to perform an ultrasound-guided procedure, and to explore potential advantages of this technology. MethodsForty participants of varying training levels were randomized into two groups. One group used Google Glass to perform an ultrasound-guided central line. The other group used traditional ultrasound during the procedure. Video recordings of eye and hand movements were analyzed. ResultsAll participants from both groups were able to complete the procedure without difficulty. Google Glass wearers took longer to perform the procedure at all training levels (medical student year 1 [MS1]: 193 s vs. 77 s, p > 0.5; MS4: 197s vs. 91s, p ≤ 0.05; postgraduate year 1 [PGY1]: 288s vs. 125 s, p > 0.5; PGY3: 151 s vs. 52 s, p ≤ 0.05), and required more needle redirections (MS1: 4.4 vs. 2.0, p > 0.5; MS4: 4.8 vs. 2.8, p > 0.5; PGY1: 4.4 vs. 2.8, p > 0.5; PGY3: 2.0 vs. 1.0, p > 0.5). ConclusionsIn this study, it was possible to perform ultrasound-guided procedures with Google Glass. Google Glass wearers, on average, took longer to gain access, and had more needle redirections, but less head movements were noted.

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

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. 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. 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. A total of 148 internal medicine and medicine-pediatrics residents inserted 639 catheters, and 53 (36%) achieved competence by the end of 4weeks. Residents judged to be competent by checklist scores had a higher composite success rate than those deemed not competent. 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.

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Transfusion Therapy

Informed consent for bedside procedures in the pediatric intensive care unit: A preliminary report

No uniform guidelines exist regarding informed consent for bedside procedures in the intensive care unit (ICU), and practice varies widely between institutions. Neither guidelines nor data exist to help pediatric ICU (PICU) directors craft procedural consent policies. We conducted an exploratory study to explore the impact on patients, parents, and healthcare providers of a requirement for informed consent for bedside procedures in the PICU and to describe parental and provider beliefs regarding procedural consent. Prospective, observational and survey-based exploratory study. Single-center, tertiary care, university-affiliated PICU. Children admitted to the PICU and undergoing an invasive bedside procedure. None. During two 14-day periods, all bedside procedures conducted in the PICU were identified. Consent forms were reviewed, and parents and the healthcare providers who participated in the consent discussion were invited to complete a brief verbal questionnaire regarding the consent process. Quantitative data are presented using descriptive statistics and qualitative data were analyzed using thematic coding. During the study period, 50 bedside procedures were performed. Informed consent was not obtained for two emergent procedures. Only the first procedure on a child was included in the study, leaving 41 informed consent discussions for analysis. Consent was obtained in person in 33 cases (80%) and over the phone for the remainder. The median reported duration of the informed consent discussion was 5 mins. Ninety-six percent of parents correctly recalled what procedure had been performed, and 92% correctly recalled at least one reason for the procedure, but only 58% recalled at least one risk of the procedure. Parents viewed themselves as the primary decision makers, and many parents believed that their refusal of consent would be honored even if it would potentially harm the child. However, no parent refused or even significantly resisted giving consent for a procedure recommended by their child's healthcare provider. Parental consent for invasive bedside procedures in the PICU can be obtained reliably and without posing an undue time burden on healthcare providers. Most parents perceive a real decision making opportunity surrounding invasive procedures, but agree readily to the recommendations of their healthcare providers.

Patient satisfaction with a hospitalist procedure service: Is bedside procedure teaching reassuring to patients?

In recent years, hospital medicine programs have adopted "procedure teams" that supervise residents in performing invasive bedside procedures. The effect of procedure teams on patient satisfaction is unknown. We sought to measure patient satisfaction with procedures performed by a hospitalist-supervised, intern-based procedure service (HPS) with a focus on patient perception of bedside communication. This was a prospective survey. We surveyed all patients referred to the HPS for bedside thoracentesis, paracentesis, lumbar puncture, and arthrocentesis at a single academic medical center. Following each procedure, surveys were administered to English-speaking patients who could provide informed consent. Survey questions focused on patients' satisfaction with specific aspects of procedure performance as well as the quality and impact of communication with the patient and between members of the team. Of 95 eligible patients, 65 (68%) completed the survey. Nearly all patients were satisfied or very satisfied with the overall experience (100%), explanation of informed consent (98%), pain control (92%), and expertise (95%) of physicians. The majority of patients were satisfied with procedure duration (88%) and in those with therapeutic procedures most (89%) were satisfied with improvement in symptoms. Hearing physicians discuss the procedure at the bedside was reassuring to most patients (84%), who felt this to be a normal part of doing a procedure (94%). Patients are highly satisfied with procedure performance by supervised trainees, and many patients were reassured by physician communication during the procedure. These results suggest that patient experience and teaching can be preserved with a hospitalist-supervised procedure service.

End of the "see one, do one, teach one" era: the next generation of invasive bedside procedural instruction.

Traditionally, an apprenticeship model has been used for the instruction of invasive bedside procedures. Because this approach is subject to nonuniform application, a new model was established to determine the impact of a standardized curriculum on medical students' and residents' medical knowledge and technical skills. A procedural instruction curriculum for medical students and residents was developed, and a pilot program with the curriculum was incorporated into an internal medicine residency program. Five common procedures in osteopathic and allopathic internal medicine training programs were included: central venous catheterization, knee arthrocentesis, lumbar puncture, paracentesis, and thoracentesis. An initial assessment of participants' baseline knowledge and skills was obtained. Teaching methods included video instruction; discussion of key concepts; faculty-led, hands-on, simulation-based instruction; and individual deliberate practice. Postinstruction knowledge and skills were evaluated, respectively, through a written test and a quantified assessment (ie, checklist) using direct observation. Participants were asked to provide written feedback at the conclusion of each instructional module. A total of 60 participants, all in allopathic medicine, underwent the training component. Fifty-two participants were internal medicine residents (including 2 from an outside program); 4 were trainees in a combined internal medicine-pediatrics residency; and 4 were medical students (1 from an outside program). Participants demonstrated a statistically significant improvement (P<.001) in medical knowledge, as evidenced by preinstruction vs postinstruction test scores. Comparison of initial baseline procedural checklist scores with postinstruction checklist scores, during participants' performance on the first live patient, also showed statistically significant improvement (P<.001). A simulation-based, standardized curriculum in invasive bedside procedural instruction significantly improved the medical knowledge and technical skills of novice physicians.

Transforming invasive bedside procedural instruction

Context and setting Because there is a lack of standardised methodology to teach invasive bedside procedures, the incidence of associated complications remains unacceptably high and variations in teaching may be a contributing factor. Successful interventions are needed to change these poor outcomes and improve patient safety. Therefore, the University of Miami-Jackson Memorial Hospital Center for Patient Safety (CPS) launched an innovative educational initiative. Specifically designed to fill the training gap, the programme provides a standardised curriculum for procedural instruction. Why the idea was necessary At academic medical centres throughout the USA, residents perform the majority of invasive bedside procedures. By contrast with the apparent flaws in the outdated and frequently unsafe ‘see one, do one, teach one’ model of training, standardised procedural training targets hands-on learning and direct observation as the keystones for building confidence and competence. What was done To capitalise on this educational opportunity, a uniform teaching method was created incorporating the six Accreditation Council for Graduate Medical Education core competencies: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. We developed a simulation-based curriculum for those procedures recently listed by the American Board of Internal Medicine as necessitating technical competence (central venous catheter insertion, lumbar puncture, paracentesis, thoracentesis), tailored for residents who will be asked to deliver these critical aspects of patient care. Our initiative combines the established, efficacious use of simulators, practice with ultrasound and the utility of checklists in ensuring patient-safe practices. To date, we have trained anaesthesiology, emergency medicine, internal medicine, neurology and surgery residents and medical students. The four pillars of the procedural training include:

Rethinking Invasive Procedural Training

To the Editor: Residency programs should offer standardized procedural instruction in tandem with team training. Why do we propose this? Consider: At academic medical centers throughout the United States, residents perform the majority of invasive bedside procedures (e.g., central venous catheter insertion, lumbar puncture). Learning typically follows the apprenticeship model of “see one, do one, teach one,” and instruction is based on the variable approaches of their teachers. Additionally, achieving confidence and competence in the performance of these procedures is unique to each trainee. Some may approach mastery yet never attain it, and thus they are identified as unable to perform specific procedures independently at the conclusion of their training. Some training programs have found ways to improve on this traditional learning approach by redefining procedural education. Simulation-based training1 (with feedback in a protected environment), ultrasound guidance2 (to minimize mechanical and infectious complications), use of a checklist3 (ensuring patient safe practice by adherence to critical steps), and team training4 (including direct observation) have been reported separately as beneficial. We and our colleagues at the University of Miami–Jackson Memorial Hospital combined these elements into a four-pronged approach, translating the knowledge and skill learned in the simulation center to the patient's bedside where residents can develop the last piece of learning and proceed to mastery under attendings' supervision. This combined approach enables residents to practice procedures both through simulation training and direct observation, to improve their confidence and competence, and ultimately to provide safer patient care. Joshua D. Lenchus, DO, RPh, FACP Assistant professor of medicine, Division of Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, associate program director, Jackson Memorial Hospital Internal Medicine Residency Training Program, and associate director, University of Miami–Jackson Memorial Hospital Center for Patient Safety, Miami, Florida; [email protected]. David J. Birnbach, MD, MPH Professor of anesthesiology and public health, University of Miami Miller School of Medicine, and director, University of Miami–Jackson Memorial Hospital Center for Patient Safety, Miami, Florida.

Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions

From the Division of Vascular and Interventional Radiology, Jefferson Radiology, Hartford Hospital, 85 Seymour St, Ste 200, Hartford, CT 06106 (P.C.M.); Department of Radiology, Boston Healthcare System, VAMC Boston, Massachusetts (C.J.G.); Department of Medical Imaging, Scarborough General Hospital, Richmond Hill, Ontario, Canada (S.K.); Department of Radiology, GI/GU Division, Massachusetts General Hospital, Boston, Massachusetts (D.A.G.); Department of Radiology and Radiologic Sciences, Uniformed Services University of the Health Sciences and Department of Radiology, National Naval Medical Center, Bethesda, Maryland (D.L.M.); RADIA, Everett, Washington (R.B.O.); Department of Radiology, University of Florida, Gainesville, Florida (D.W.P.); Department of Medical Imaging, Division of Vascular and Interventional Radiology, University of Toronto, University Health Network, Toronto, Ontario, Canada (D.K.R.); Department of Interventional Radiology, The Reading Hospital and Medical Center, West Reading, Pennsylvania (D.S.); Radiology Associates of Central Florida, Mt Dora, Florida (M.S.S.); Mallinckrodt Institute of Radiology, St Louis, Missouri (D.A.Z.); and Geisinger System Radiology, Geisinger Health System, Danville, Pennsylvania (J.F.C.). Received November 18, 2008; accepted November 24, 2008. Address correspondence to P.C.M.; E-mail: pmalloy@ jeffersonradiology.com

Complications of care in a pediatric intensive care unit: a prospective study.

(a) To examine the frequency, type, and severity of complications occurring in a pediatric intensive care unit; (b) to identify populations at risk; and (c) to study the impact of complications on morbidity and mortality. Prospective survey. Pediatric intensive care unit (PICU) of a university-affiliated hospital. 1035 consecutive admissions over an 18-month period. 115 complications occurred during 83 (8.0%) admissions, for 2.7 complications per 100 PICU-days; 48 (42%) complications were major, 45 (39%) moderate, and 22 (19%) minor. Sixty complications (52%) were ventilator-related, 14 were drug-related, 13 procedure-related, 24 infectious, and 22 involved invasive devices (18 vascular catheters). Human error was involved in 41 (36%) cases, 21 of which were major (18%). Treatments included reintubation < 24 h (28), intravenous antimicrobials (24), and invasive bedside procedures (14). Cardiopulmonary resuscitation was required in 6 patients. Thirteen patients with complications died (15.7%); 2 deaths were directly due to complications. Patients with complications were younger, had longer lengths of stay, and had a higher mortality. Length of stay was a positive risk factor for complication risk (odds ratio = 1.09, 95% confidence interval: 1.05 to 1.13; p = 0.0001); other patient characteristics had no predictive effect. Kaplan-Meier estimates showed that the most severe complications occurred early in the PICU stay. The best indicators of patient mortality were number of complications (odds ratio = 2.96, 95% confidence interval 1.72 to 5.08; p = 0.0001), and mortality risk derived from the Pediatric Risk of Mortality Score (odds ratio = 1.08, 95% confidence interval 1.06 to 1.10; p = 0.0001). Mortality was correlated with increasing severity of complications. Complications have a significant impact on patient care. Patients may be at increased risk earlier in their PICU course, when the number of interventions may be greatest. Complications may increase patient mortality and predict patient death better than other patient variables.

Atlas of Bedside Procedures

Only rarely does an editor fulfill his objective as well as VanderSalm, Cutler, and Wheeler have. They set out to provide an atlas for senior medical students and junior residents that would explicitly and plainly describe the indications, techniques, and complications of invasive bedside procedures. They succeeded in producing a manual that should supply a solid conceptual framework to the surgeon training to perform all types of procedures commonly done in intensive care units, emergency rooms, and the surgical wards. Although atlases of this type can regress to cookbook format, this textbook definitely does not. The outline format and schematic drawings are clear and easy to follow. The techniques described were selected as those most successful in the author's experience. The list of complications is complete, and the bibliography, which is mostly annotated, is an excellent reference source. Minor complaints might be directed at inclusion of highly specialized procedures, such