Pediatric emergency medicine fellows and attendings have few opportunities to perform critical procedures, even in busy pediatric EDs, which jeopardizes their ability to achieve and maintain competency, according to new research.
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“When we tallied the numbers, the exposure rates were surprisingly low,” said Matthew Mattiga, MD, an assistant professor of clinical pediatrics at the Cincinnati Children's Hospital Medical Center. But the findings weren't exactly a surprise, he said, because he and his colleagues knew from experience that opportunities to perform such procedures had been rare during their training. That's true even in his ED that sees more than 90,000 visits a year.
“Once you are out of training, the requirements become less than they were in training. How do faculty members maintain these skills? Once a faculty member, unless your hospital has credentialing requirements, people could go long periods of time without performing these procedures on kids,” he said.
Cincinnati Children's is one of the busiest EDs in the nation, but their review of the records of 3,067 children treated in the ED's four resuscitations bays from April 2009 through March 2010 found only 261 critical procedures performed in 194 evaluations. Critical procedures included defibrillation, intubation, cricothyroidotomy, thoracostomy, pericardiocentesis, and intraosseous line placement. (See table for complete list of critical procedures.) Forty-one pediatric emergency medicine faculty and 10 physicians enrolled in the clinical portion of the pediatric emergency medicine fellowship. (Ann Emerg Med 2013;61:263.)
Sixty-one percent of the pediatric emergency medicine faculty did not perform a single critical procedure, and not one faculty provider performed more than six critical procedures. Twenty-six faculty (63%) did not perform a single successful orotracheal intubation, which was the most common critical procedure in the study. Ten of the faculty performed it one to two times, and four performed it three to four times; one faculty member performed five orotracheal intubations.
The researchers estimated that a faculty member would require nearly six eight-hour shifts to supervise one resuscitation during which at least one critical procedure was performed. The review showed that pediatric emergency medicine fellows performed a median of three critical procedures during the study period (range, 0-9). Fellows performed a median of 2.5 orotracheal intubations (range, 0-9) and a median of 0.5 intraosseous line placements (range, 0-9).
“Although the 10 pediatric emergency medicine fellows performed as many critical procedures as the 41 faculty, no fellow performed a central venous line placement, needle thoracostomy, or pericardiocentesis in the pediatric ED during the study period,” the authors wrote. “Only half of the fellows performed an intraosseous line placement, and just 30 percent performed a tube thoracostomy. Fellows performed a median of 2.5 orotracheal intubations compared with a faculty median of zero, but 40 percent of the fellows performed one or fewer.”
But the situation is not as dire as it sounds, according to an editorial by Steven M. Green, MD, a professor of emergency medicine at Loma Linda (CA) University School of Medicine. (Ann Emerg Med 2013;61:280.) He proposed three solutions to the issue, starting with expanded didactic sessions, airway procedure laboratories, and simulation sessions along with more clinical rotations in critical care and anesthesia where pediatric emergency physicians could perform additional procedures. He also said fewer emergency medicine fellows could be trained in a specially reserved critical care area in the ED for the small numbers of very sick children, increasing the average number of critical procedures performed per fellow. A final alternative, he said, would be to make pediatric emergency medicine a “cognitive” subspecialty not expected to perform critical procedures without backup.
Acknowledging that would be an unpopular option, Dr. Green stressed that pediatric emergency physicians add undeniable value above and beyond the general emergency medicine corpus. “Their more comprehensive and focused pediatric knowledge can permit them to often go the next step while the child is still in the ED, more rapidly arriving at the final diagnosis and optimal treatment strategy,” he said. “These subspecialists also … go beyond just the chief complaint to frame the ED visit in the context of the child's underlying medical and behavioral situation. These added capabilities are useful and worthwhile, but they are not essential for an ED. It is imperative that the subspecialty develops a meaningful plan to ensure the quality provision of core critical care procedures on those occasions when they are necessary.”
Marc Gorelick, MD, the vice chair of emergency medicine at Children's Hospital of Wisconsin and a member of the American Academy of Pediatrics Committee on Pediatric Emergency Medicine, said the subspecialty involves more than critical procedures, and is distinguished by the ability to evaluate an undifferentiated complaint and to discriminate between the seriously ill and the less-ill.
But the study raises an important point, he said, noting that a child who needs a critical procedure should receive it from a person who is highly skilled, even if performing that procedure is just a small part of being a pediatric emergency physician. Simulation training and maintaining skills in alternative settings is important, he said. “That's the reason trainees spend time in anesthesia and in the trauma service,” Dr. Gorelick said. The study “underscores the need to set up systems of care that ensure that we are giving opportunities for physicians to build and maintain skills.”
Dr. Mattiga, who also serves as the assistant fellowship director in his program, said it is imperative for him to ensure that fellows are well trained and prepared to live up to expectations. “We want people to know if they bring a gravely ill child to you, you can do the job,” he said. His program already has a robust medical simulation program with high-fidelity human simulators that helps fellows anticipate what could go wrong, though Dr. Mattiga conceded it is not the same as a real person.
“We bring the simulator into the emergency department unannounced, and set it up in a trauma bay,” he said. “Then we announce that a seriously ill patient has arrived. When the team gets there, all the equipment is right there.” He said this practice only scratches the surface of the fellows' needs, however.
He also advocates “deliberate practice,” the process of reviewing different scenarios and planning how to perform in each. “People who do the job really well go through it in their heads. First, they get a little nervous, but accommodate that by going through that just as an athletic team would do in getting ready for a big game.”
One thing Dr. Mattiga said he preaches to trainees and fellows is that they must meet the societal expectation that all emergency physicians are ready for whatever walks through the door. “That raises the question about how we prepare,” he said. “Clearly, waiting to do the allotted procedures that come your way each year is not adequate.”
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