Chief residents run a procedure service

Background

Back in 2010, medical residents at the University of Texas Health San Antonio learned and performed procedures in the traditional manner. “See one, do one, teach one,” said Robert Nathanson, MD, FACP. “Residents would get on-the-fly instruction by whatever attending they were working with at the time, and then, after very little instruction, they would be tasked with doing them on their own and then subsequently teaching them.”

The shortcomings of that model were clear, according to Dr. Nathanson, who is an associate professor, a hospitalist, and director of University of Texas Health San Antonio's medicine procedure service. “You don't build up enough confidence or competence in procedures, and it could potentially lead to some bad outcomes.”

In 2011, faculty decided to tackle those problems by enlisting their chief residents and point-of-care ultrasound (POCUS) technology.

How it works

The new procedure service consisted of two to three medicine interns at a time assigned to a four-week procedures, patient safety, and POCUS rotation, supervised by an internal medicine chief resident. Using didactics and simulation, the chief residents trained the interns to provide ultrasound-guided procedures including paracentesis, thoracentesis, lumbar puncture, knee arthrocentesis, and internal jugular vein catheterization, and then supervised as they performed them, 8 a.m. to 5 p.m., Monday through Friday. The chief residents, in turn, were trained by the procedure service director during the two months before they took over the service at the start of a new academic year.

Results

The trainees logged the results of every procedure performed, and after 10 years, the program leaders crunched the numbers. The service had attempted 4,465 procedures, with an overall success rate of 94%; only 2.6% of procedures had complications, and 0.6% of them were major. Interns also gave the rotation a 4.6 out of 5 rating, according to results published by the Journal of General Internal Medicine on May 26.

“We had a good feeling that our results would be comparable to other studies out there of purely attending-led services, and we were excited to see that our results were really on par,” said Dr. Nathanson. “We're providing quality education for our interns. They're able to do procedures successfully and with minimal risk and complication, which of course benefits our patients as well as our learners.”

Next steps

The procedure team isn't resting on its laurels, though. The study found that the service's lowest success rate and highest complication rate were with lumbar punctures, at 76% and 4.5%, respectively. Those figures are similar to other published statistics but offer an opportunity for improvement, according to Dr. Nathanson.

“We're using that information to guide future simulation efforts to bolster the training of our residents and chief residents in lumbar puncture, as well as looking at alternative techniques,” he said. Such alternatives include the paramedian approach to lumbar puncture, which is used more commonly by anesthesiologists than by internal medicine physicians.

Challenges

The biggest challenges in launching the resident procedure service were logistical, according to Dr. Nathanson: “setting up the service, advertising it to both of our hospitals, having enough ultrasound equipment and appropriate procedural supplies, some of the local policies and documentation that had to be ironed out.”

It was also key to have POCUS-trained faculty with time available to lead and supervise the program. “After that, it just requires the buy-in of your program director to utilize the chief residents for the staffing as well as their time to help lead the service,” Dr. Nathanson said.

Words of wisdom

Given the equipment and time required to launch a medical procedure service, Dr. Nathanson advises gradually scaling up. “It's OK to start small in terms of what sorts of procedures you offer,” he said. “For a service that is grappling with acquiring resources such as training mannequins for the various procedures, it may be best to start with those core three procedures of paracentesis, thoracentesis, and lumbar puncture.”

Lessons learned

Academic hospitalists who are interested in procedures have lots of company, Dr. Nathanson noted. “There's this collaborative group that's called PRIME where a lot of procedural experts across the country are getting together and looking at gaps in the literature and how to really advance this field of procedure teams within internal medicine,” he said.