Irene W. Y. Ma

Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis.

Purpose Central venous catheterization (CVC) is increasingly taught by simulation. The authors reviewed the literature on the effects of simulation training in CVC on learner and clinical outcomes. Method The authors searched computerized databases (1950 to May 2010), reference lists, and considered studies with a control group (without simulation education intervention). Two independent assessors reviewed the retrieved citations. Independent data abstraction was performed on study design, study quality score, learner characteristics, sample size, components of interventional curriculum, outcomes assessed, and method of assessment. Learner outcomes included performance measures on simulators, knowledge, and confidence. Patient outcomes included number of needle passes, arterial puncture, pneumothorax, and catheter-related infections. Results Twenty studies were identified. Simulation-based education was associated with significant improvements in learner outcomes: performance on simulators (standardized mean difference [SMD] 0.60 [95% CI 0.45 to 0.76]), knowledge (SMD 0.60 [95% CI 0.35 to 0.84]), and confidence (SMD 0.41 [95% CI 0.30 to 0.53] for studies with single-group pretest and posttest design; SMD 0.52 (95% CI 0.23 to 0.81) for studies with nonrandomized, two-group design). Furthermore, simulation-based education was associated with improved patient outcomes, including fewer needle passes (SMD −0.58 [95% CI −0.95 to −0.20]), and pneumothorax (relative risk 0.62 [95% CI 0.40 to 0.97]), for studies with nonrandomized, two-group design. However, simulation-based training was not associated with a significant reduction in risk of either arterial puncture or catheter-related infections. Conclusions Despite some limitations in the literature reviewed, evidence suggests that simulation-based education for CVC provides benefits in learner and select clinical outcomes.

Cognitive load imposed by knobology may adversely affect learners' perception of utility in using ultrasonography to learn physical examination skills, but not anatomy

Ultrasonography is increasingly used for teaching anatomy and physical examination skills but its effect on cognitive load is unknown. This study aimed to determine ultrasounds perceived utility for learning, and to investigate the effect of cognitive load on its perceived utility. Consenting first‐year medical students (n = 137) completed ultrasound training that includes a didactic component and four ultrasound‐guided anatomy and physical examination teaching sessions. Learners then completed a survey on comfort with physical examination techniques (three items; alpha = 0.77), perceived utility of ultrasound in learning (two items; alpha = 0.89), and cognitive load on ultrasound use [measured with a validated nine‐point scale (10 items; alpha = 0.88)]. Learners found ultrasound useful for learning for both anatomy and physical examination (mean 4.2 ± 0.9 and 4.4 ± 0.8, respectively; where 1 = very useless and 5 = very useful). Principal components analysis on the cognitive load survey revealed two factors, “image interpretation” and “basic knobology,” which accounted for 60.3% of total variance. Weighted factor scores were not associated with perceived utility in learning anatomy (beta = 0.01, P = 0.62 for “image interpretation” and beta = −0.04, P = 0.33 for “basic knobology”). However, factor score on “knobology” was inversely associated with perceived utility for learning physical examination (beta = −0.06; P = 0.03). While a basic introduction to ultrasound may suffice for teaching anatomy, more training may be required for teaching physical examination. Prior to teaching physical examination skills with ultrasonography, we recommend ensuring that learners have sufficient knobology skills. Anat Sci Educ 8: 197–204.

Diagnosing technical competence in six bedside procedures: comparing checklists and a global rating scale in the assessment of resident performance.

Purpose To compare procedure-specific checklists and a global rating scale in assessing technical competence. Method Two trained raters used procedure-specific checklists and a global rating scale to independently evaluate 218 video-recorded performances of six bedside procedures of varying complexity for technical competence. The procedures were completed by 47 residents participating in a formative simulation-based objective structured clinical examination at the University of Calgary in 2011. Pass/fail (competent/not competent) decisions were based on an overall global assessment item on the global rating scale. Raters provided written comments on performances they deemed not competent. Checklist minimum passing levels were set using traditional standard-setting methods. Results For each procedure, the global rating scale demonstrated higher internal reliability and lower interrater reliability than the checklist. However, interrater reliability was almost perfect for decisions on competence using the overall global assessment (Kappa range: 0.84–1.00). Clinically significant procedural errors were most often cited as reasons for ratings of not competent. Using checklist scores to diagnose competence demonstrated acceptable discrimination: The area under the curve ranged from 0.84 (95% CI 0.72–0.97) to 0.93 (95% CI 0.82–1.00). Checklist minimum passing levels demonstrated high sensitivity but low specificity for diagnosing competence. Conclusions Assessment using a global rating scale may be superior to assessment using a checklist for evaluation of technical competence. Traditional standard-setting methods may establish checklist cut scores with too-low specificity: High checklist scores did not rule out incompetence. The role of clinically significant errors in determining procedural competence should be further evaluated.

Measuring competence in central venous catheterization: a systematic-review

ObjectivesCentral venous catheterization is a complex procedural skill. This study evaluates existing published tools on this procedure and systematically summarizes key competencies for the assessment of this technical skill.MethodsUsing a previously published meta-analysis search strategy, we conducted a systematic review of published assessment tools using the electronic databases PubMed, MEDLINE, Education Resource Information Center (ERIC), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica, and Cochrane Central Register of Controlled Trials. Two independent investigators abstracted information on tool content and characteristics.ResultsTwenty-five studies were identified assessing a total of 147 items. Tools used for assessment at the bedside (clinical tools) had a higher % of items representing “preparation” and “infection control” than tools used for assessment using simulation (67 ± 26% vs. 32 ± 26%; p = 0.003 for “preparation” and 60 ± 41% vs. 11 ± 17%; p = 0.002 for “infection control”, respectively). Simulation tools had a higher % of items on “procedural competence” than clinical tools (60 ± 36% vs. 17 ± 15%; p = 0.002). Items in the domains of “Team working” and “Communication and working with the patient” were frequently under-represented.ConclusionThis study presents a comprehensive review of existing checklist items for the assessment of central venous catheterization. Although many key competencies are currently assessed by existing published tools, some domains may be under-represented by select tools.

Cognitive load imposed by ultrasound‐facilitated teaching does not adversely affect gross anatomy learning outcomes

Ultrasonography is increasingly used in medical education, but its impact on learning outcomes is unclear. Adding ultrasound may facilitate learning, but may also potentially overwhelm novice learners. Based upon the framework of cognitive load theory, this study seeks to evaluate the relationship between cognitive load associated with using ultrasound and learning outcomes. The use of ultrasound was hypothesized to facilitate learning in anatomy for 161 novice first‐year medical students. Using linear regression analyses, the relationship between reported cognitive load on using ultrasound and learning outcomes as measured by anatomy laboratory examination scores four weeks after ultrasound‐guided anatomy training was evaluated in consenting students. Second anatomy examination scores of students who were taught anatomy with ultrasound were compared with historical controls (those not taught with ultrasound). Ultrasounds perceived utility for learning was measured on a five‐point scale. Cognitive load on using ultrasound was measured on a nine‐point scale. Primary outcome was the laboratory examination score (60 questions). Learners found ultrasound useful for learning. Weighted factor score on “image interpretation” was negatively, but insignificantly, associated with examination scores [F (1,135) = 0.28, beta = −0.22; P = 0.61]. Weighted factor score on “basic knobology” was positively and insignificantly associated with scores; [F (1,138) = 0.27, beta = 0.42; P = 0.60]. Cohorts exposed to ultrasound had significantly higher scores than historical controls (82.4% ± SD 8.6% vs. 78.8% ± 8.5%, Cohens d = 0.41, P < 0.001). Using ultrasound to teach anatomy does not negatively impact learning and may improve learning outcomes. Anat Sci Educ 10: 144–151.

Use of an error-focused checklist to identify incompetence in lumbar puncture performances

Checklists are commonly used in the assessment of procedural competence. However, on most checklists, high scores are often unable to rule out incompetence as the commission of a few serious procedural errors typically results in only a minimal reduction in performance score. We hypothesised that checklists constructed based on procedural errors may be better at identifying incompetence.

Treatment Options for Pediatric Patent Ductus Arteriosus: Systematic Review and Meta-analysis

BACKGROUND Patent ductus arteriosus (PDA) in the nonpremature pediatric patient is currently treated by surgical ligation or catheter occlusion. There is no clear superiority of one technique over the other. This meta-analysis compares the clinical outcomes of the two treatment options for PDA. METHODS We performed a literature search of MEDLINE, Embase, PubMed, and the Cochrane database of randomized controlled trials (RCTs) that took place between 1950 and February 2014 and hand-searched references from included studies. We excluded studies of adult or premature patients and those without a direct comparison between surgical and catheter-based treatments of PDAs. Outcomes of interest were reintervention, total complications, length of stay, and cost. RESULTS One thousand three hundred thirty-three manuscripts were screened. Eight studies fulfilled the inclusion criteria (one RCT and seven observational studies [N = 1,107]). In pooled observational studies, there were significantly decreased odds (OR, 0.12; 95% CI, 0.03-0.42) for reintervention in the surgical ligation group but insignificantly higher odds for overall complications (OR, 2.01; 95% CI, 0.68-5.91). There were no complications reported in the RCT, but surgical ligation was associated with decreased odds for reintervention and a longer length of stay. Funnel plots revealed a possible publication bias and a quality review identified comparability bias. CONCLUSIONS Both therapies have comparable outcomes. Reintervention is more common with catheter-based treatment, but overall complication rates are not higher and hospital stay is shorter. Our data span > 2 decades and may not reflect current surgical and catheterization outcomes. Large, randomized, prospective studies may help determine the optimal treatment strategy.

Notes from the Field: Direct Observation Versus Rating by Videos for the Assessment of Central Venous Catheterization Skills

Blinded assessments of technical skills using video-recordings may offer more objective assessments than direct observations. This study seeks to compare these two modalities. Two trained assessors independently assessed 18 central venous catheterization performances by direct observation and video-recorded assessments using two tools. Although sound quality was deemed adequate in all videos, portions of the video for wire handling and drape handling were frequently out of view (n = 13, 72% for wire-handling; n = 17, 94% for drape-handling). There were no differences in summary global rating scores, checklist scores, or pass/fail decisions for either modality (p > 0.05). Inter-rater reliability was acceptable for both modalities. Of the 26 discrepancies identified between direct observation and video-recorded assessments, three discrepancies (12%) were due to inattention during video review, while one (4%) discrepancy was due to inattention during direct observation. In conclusion, although scores did not differ between the two assessment modalities, techniques of video-recording may significantly impact individual items of assessments.

In defence of teaching point-of-care ultrasound in undergraduate medical education

We read with interest Feilchenfeld et al.’s article titled ‘Ultrasound in undergraduate medical education: a systematic and critical review’. We commend the authors for the excellent and careful discourse analyses of existing point of care ultrasound (POCUS) education literature. As internists with expertise in POCUS, we feel compelled to ensure that the messages portrayed in the article are clinically accurate and to present an alternate view of the potential merits of teaching POCUS.