Weekly Article: Critical procedures are sparse in the ED

by Priya Gopwani

For all of you who haven’t been able to make it to Pavan’s procedural/sim sessions, this one is for you!

The article I chose has to do with the comfort of PEM providers in doing critical procedures (pharmacologic and electric cardioversion, defibrillation, nasotracheal and orotracheal intubation, needle cricothyroidotomy, tube thoracostomy, pericardiocentesis, DPL, thoracentesis, a-line, venous cutdown line placement, IOs and central venous lines). The study was done at Cincinnati Children’s, and was a retrospective review of their medical records. The looked at medical and trauma patients that were seen in their trauma bays (which seem to be equivalent to our traumas and med alerts). Unsuccessful attempts were NOT counted as “successfully performing a procedure” (obviously), and supervision of a procedure that someone else performed did not count either.

In their 1 year study, they had a total of 261 critical procedures (and NO external cardiac pacing, nasotracheal intubation, needle cric, DPL, thoracentesis, a-line or venous cutdown). 61% of the 41 PEM faculty did not perform a single critical procedure. No faculty performed >6 procedures. They extrapolated their data to calculate “projected number of clinical hours necessary for a PEM faculty to perform a successful critical procedure”. The table is on page 267, but some examples are:

292 hours worked to perform 1 successful orotracheal intubation

4380 hours worked to perform 1 successful central line placement

8760 hours worked to perform 1 successful tube thoracostomy

They go on to discuss ways to keep faculty comfortable with procedures (doing them all, but then how would the fellows/residents ever learn?), and suggest simulation as “an opportunity for deliberate practice with feedback immediately available to the learner and no risk of harm to patients”. From here, they are creating a procedural sim program for their faculty and fellows to improve and maintain skills.
So Pavan, when is your next sim session again?

Mittiga M et al (2013). The spectrum and frequency of critical procedures performed in a pediatric emergency department. Annals of Emergency Medicine.