A feasibility study of a handmade ultrasound-guided phantom for paracentesis.

BACKGROUND: Simulation-based training is effective for ultrasound (US)-guided procedures. However, commercially developed simulators are costly. This study aims to evaluate the feasibility of a hand-made phantom for US-guided paracentesis. METHODS: We described the recipe to prepare an agar phantom. We collected the US performance data of 50 novices, including 22 postgraduate-year (PGY) residents and 28 undergraduate-year (UGY) students, who used the phantom for training, as well as 12 emergency residents with prior US-guided experience. We obtained the feedback after using the phantom with the Likert 5-point scale. The data were presented with medians and interquartile ranges (IQRs) and analyzed by the Wilcoxon rank sum test. RESULTS: While emergency residents demonstrated superior performance compared to trainees, all trainees exhibited acceptable proficiency (global rating of ≥ 3, 50/50 vs. 12/12, p = 1.000) and comparable needle steadiness [5 (5) vs. 5 (5), p = 0.223]. No significant difference in performance was observed between PGYs [5 (4-5)] and UGYs [5 (4-5), p = 0.825]. No significant differences were observed in terms of image stimulation, puncture texture, needle visualization, drainage simulation, and endurance of the phantom between emergency residents and trainees. However, experienced residents rated puncture texture and draining fluid as "neutral" (3/5 on the Likert scale). The cost of the paracentesis phantom is US$16.00 for at least 30 simulations, reducing it to US$6.00 without a container. CONCLUSIONS: The paracentesis phantom proves to be a practical and cost-effective training tool. It enables novices to acquire paracentesis skills, enhances their US proficiency, and boosts their confidence. Nevertheless, further investigation is needed to assess its long-term impact on clinical performance in real patients. TRIAL REGISTRATION: NCT04792203 at the ClinicalTrials.gov.

Competency-based assessment of procedural skills in resident training.

BACKGROUND: No standardized summative tools exist to assess competency in bedside procedures or provide residents and programs with summative feedback. OBJECTIVE: To provide competency-based procedure training and feedback to residents, we created a procedure competency committee (PCC). Here, we describe the PCC process, its impact on procedure training, and examine residents' attainment of competency in bedside procedures. DESIGN, SETTING, AND PARTICIPANTS: The PCC consisted of hospitalists and met twice annually to review resident procedure portfolios for three academic years 2019-2022 at a university-based internal medicine residency program. Residents were designated to one of the five competency levels; being able to participate, perform under supervision with assistance, perform under direct supervision (DS) without assistance, perform independently with indirect supervision (IS), and perform independently with IS and supervise others. We analyzed the probability of advancing competency levels with each additional procedure using multinomial logistic regression models. RESULTS: Of the 97 residents, 48 (49.5%) were women and 60 (62%) subsequently matched in procedure-oriented fields. More residents achieved IS level for paracentesis than for lumbar puncture (LP) or central venous catheterization (CVC) (62 vs. 25 and 37, respectively; p < .001). Each incremental procedure performed was associated with a higher chance of being advanced to IS group from the DS group; 1.31 times for paracentesis (95% confidence interval [CI] = 1.07, 1.60; p < .008), 1.83 times for LP (95% CI = 1.35, 2.47; p = .0001), and two times for CVC (95% CI = 1.32, 3.05; p = .001). CONCLUSION: The PCC provided competency-based assessment of a resident's procedural skills and may be used to assess the impact of curriculum changes.

Assembly and use of a low-cost paracentesis simulator for the teaching of puncture and drainage of ascites.

OBJECTIVES: to describe the assembly of a low-cost paracentesis simulator and evaluate its effectiveness, acceptance and impact on the learning of medical students. METHODOLOGY: a paracentesis simulator was built using a mannequin and materials such as plastic bottles, Velcro, polyvinyl chloride sheets and silicone were used. A cross-sectional and experimental study was carried out with undergraduate medical students without previous practical experience with paracentesis, which sought to validate the model, evaluating its benefits in learning and obtaining technical skills. RESULTS: after using the simulator there was an increase of 82.4% in the level of confidence in performing paracentesis in a patient, with 98% of respondents considering that the model fulfilled the simulator function with satisfaction, and 100% considering it useful as a teaching tool. CONCLUSION: the built simulator was effective as an educational resource, serving as an alternative to high-cost commercial models, allowing for greater accessibility in the use of this tool in medical education.

Assembly and use of a low-cost paracentesis simulator for the teaching of puncture and drainage of ascites / Montagem e uso de simulador de paracentese de baixo custo - aplicabilidade no ensino de punção e drenagem de ascite

ABSTRACT Objectives: to describe the assembly of a low-cost paracentesis simulator and evaluate its effectiveness, acceptance and impact on the learning of medical students. Methodology: a paracentesis simulator was built using a mannequin and materials such as plastic bottles, Velcro, polyvinyl chloride sheets and silicone were used. A cross-sectional and experimental study was carried out with undergraduate medical students without previous practical experience with paracentesis, which sought to validate the model, evaluating its benefits in learning and obtaining technical skills. Results: after using the simulator there was an increase of 82.4% in the level of confidence in performing paracentesis in a patient, with 98% of respondents considering that the model fulfilled the simulator function with satisfaction, and 100% considering it useful as a teaching tool. Conclusion: the built simulator was effective as an educational resource, serving as an alternative to high-cost commercial models, allowing for greater accessibility in the use of this tool in medical education.

RESUMO Objetivos: descrever a montagem de simulador de paracentese de baixo custo e avaliar eficácia, aceitação e impacto no aprendizado de acadêmicos do curso de medicina. Método: um simulador de paracentese foi construído a partir de manequim e de materiais como garrafas plásticas, velcro, folhas de policloreto de vinila e silicone. Foi feito estudo transversal com estudantes da graduação do curso de medicina sem experiência real prévia com paracentese, que buscou validar o modelo, por meio da análise de benefícios no aprendizado e na obtenção de habilidades técnicas. Resultados: após o uso do simulador, observou-se aumento de 82,4% no nível de segurança na realização da paracentese em paciente, 98% dos pesquisados consideraram que o uso do modelo cumpriu com satisfação a função de simulador e 100% definiram-no útil como ferramenta de ensino. Conclusão: a montagem do simulador mostrou-se factível e eficaz como recurso educacional. Serviu como alternativa aos modelos comerciais de alto custo e permitiu maior acessibilidade do uso dessa ferramenta na educação médica.

Measuring the effect of a competency-based education conference for PAs and NPs.

OBJECTIVE: To evaluate the effectiveness of a competency-based continuing medical education (CME) conference model for physician assistants (PAs) and NPs. METHODS: This mixed-method research included a pretest/post-test assessment of knowledge and procedural assessment for six clinical skills, along with an open-ended survey to assess the value of an educational conference for PAs and NPs (N = 48) in an urban academic healthcare facility. RESULTS: Significant increases in knowledge scores and all six clinical skill procedures were noted from pre- to post-test. Participants said they acquired new techniques and knowledge (55%) or improved current knowledge and skills (40%). CONCLUSIONS: The competency-based conference model could serve as a viable method for providing evidence-based learning and informed practice as well as instilling reflective practice and a commitment to personal growth.

Development and evaluation of a training model for paracentetic suprapubic cystostomy and catheterization.

OBJECTIVES: Minimally invasive paracentetic suprapubic cystostomy is a technique that should be learned by all surgical trainees and residents. This study aimed to develop a self-made training model for paracentetic suprapubic cystostomy and placement of the suprapubic catheter and then to evaluate its effectiveness in training fourth-year medical students. METHODS: Medical students were divided into an experimental group receiving comprehensive training involving literature, video, and model use and a control group receiving all the same training protocols as the experimental group except without hands-on practice using the model. Each student's performance was video-recorded, followed by subjective and objective evaluations by urology experts and statistical analysis. RESULTS: All students completed the surgical procedures successfully. The experimental group's performance scores were significantly higher than those of the control group (median final performance scores of 91.0 vs. 86.8, respectively). Excellent scores were achieved by more students in the experimental group than in the control group (55% vs. 20%), and fewer poor scores were observed in the experimental group than in the control group (5% vs. 30%). CONCLUSIONS: Based on its cost-effectiveness, reusability, and training effectiveness, this paracentetic suprapubic cystostomy training model is able to achieve goals in teaching practice quickly and easily. Use of the model should be encouraged for training senior medical students and resident physicians who may be expected to perform emergent suprapubic catheter insertion at some time.

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine.

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Simulated training program in abdominal paracentesis for undergraduate medical students.

BACKGROUND AND AIMS: Abdominal paracentesis is an area that every general physician should know about, and the current learning model is unsafe for patients. Simulation allows students to develop their skills prior to clinical confrontation with minimal risks. The aims of this study were to design and evaluate a paracentesis simulation workshop for undergraduate students. METHODS: A workshop was implemented using a specially designed and validated simulation model for abdominal paracentesis. The simulated technique considered the recognition of materials, operator equipment, asepsis, anesthesia, puncture and obtaining liquid, collecting samples for analysis, withdrawal of the material and occlusion. A 24-point direct observation checklist was administered to assess the student. We assessed two students at the beginning of the workshop and all the students at the end. A perception survey was applied to attendees at the end of the workshop. RESULTS: 247 students were included and a workshop that involved 8 students per session was held. Students significantly improved their skills comparing pre- and post-evaluation results [13.36±4.46 (55.7%) vs. 22.3±1.83 (92.9%) respectively (n=69) p<0.001]. The students' perception questionnaire (n=38) showed that the training sessions were highly valued, averaging 4.8±0.38 on a Likert scale of 1-5. CONCLUSIONS: Simulated training in abdominal paracentesis is a very good teaching method. This teaching methodology should be highly recommended as an educational strategy in medicine because it could accelerate the acquisition of clinical skills in a safe learning environment.

Graduating Fellows' Procedural Comfort Level With Pulmonary Critical Care Procedures.

BACKGROUND: Graduating fellows from pulmonary and critical care programs are expected to independently perform bronchoscopy and common medical procedures in the intensive care unit. Given variable exposure and learning opportunities at different training programs, little is known about how comfortable graduating fellows are with these procedures. METHODS: A survey concerning the ACGME required procedures for pulmonary and critical care fellowship was sent to graduating fellows and program directors at all ACGME accredited subspecialty fellowship programs in pulmonary, critical care, and combined pulmonary critical care medicine. RESULTS: Critical care fellows performed the most intubations, paracenteses, arterial lines, central venous catheter insertions, and cardioversions, but did not perform as many bronchoscopy related procedures as the other subgroups. Pulmonary and combined pulmonary/critical care fellows performed and felt confident in most procedures. Program directors from all specialties agreed with the fellows overall about the procedural confidence gained during training. There also appeared to be a correlation between number of procedures performed and the confidence of the proceduralist. There appears to be a certain threshold number of successful completions to achieve confidence for independent practice for each surveyed procedure. CONCLUSION: There is a correlation between a fellow's procedural comfort with independent practice and the number of successful attempts by a graduating fellow. There are no universal guidelines that outline the appropriate number of successful attempts needed for independent practice, and our data strongly suggests that there is a threshold for each procedure across these three subspecialties.

Development and evaluation of a training model for paracentetic suprapubic cystostomy and catheterization

OBJECTIVES: Minimally invasive paracentetic suprapubic cystostomy is a technique that should be learned by all surgical trainees and residents. This study aimed to develop a self-made training model for paracentetic suprapubic cystostomy and placement of the suprapubic catheter and then to evaluate its effectiveness in training fourth-year medical students. METHODS: Medical students were divided into an experimental group receiving comprehensive training involving literature, video, and model use and a control group receiving all the same training protocols as the experimental group except without hands-on practice using the model. Each student's performance was video-recorded, followed by subjective and objective evaluations by urology experts and statistical analysis. RESULTS: All students completed the surgical procedures successfully. The experimental group's performance scores were significantly higher than those of the control group (median final performance scores of 91.0 vs. 86.8, respectively). Excellent scores were achieved by more students in the experimental group than in the control group (55% vs. 20%), and fewer poor scores were observed in the experimental group than in the control group (5% vs. 30%). CONCLUSIONS: Based on its cost-effectiveness, reusability, and training effectiveness, this paracentetic suprapubic cystostomy training model is able to achieve goals in teaching practice quickly and easily. Use of the model should be encouraged for training senior medical students and resident physicians who may be expected to perform emergent suprapubic catheter insertion at some time.

A antiga técnica em um novo estilo: desenvolvendo habilidades procedimentais em paracentese em simulador de baixo custo / The old one technique in a new style: developing procedural skills in paracentesis in a low cost simulator model

ABSTRACT BACKGROUND: Paracentesis is a routine medical procedure quite relevant in clinical practice. There are risks of complications related to paracentesis, so it is essential a proper trainee for the younger practicer. OBJECTIVE: The article describes the construction and the application of a low cost paracentesis simulator for undergraduate medical students and it also describes the perception of students about the simulator as well. METHODS: A low-cost model was developed by the Program of Tutorial Education for training medical students during three editions of an undergraduate theoretical-practical course of bedside invasive procedures. The authors constructed a model from very low-cost and easily accessible materials, such as commercial dummy plus wooden and plastic supports to represent the abdomen, synthetic leather fabric for the skin, upholstered sponge coated with plastic film to represent the abdominal wall and procedure gloves with water mixed with paint to simulate the ascitic fluid and other abdominal structures. One semi-structured form with quantitative and qualitative questions was applied for medical specialists and students in order to evaluate the paracentesis simulator. RESULTS: The paracentesis model has an initial cost of US$22.00 / R$70.00 for 30 simulations and US$16.00 / R$50.00 for every 30 additional simulations. It was tested by eight medical doctors, including clinical medicine, general surgeons and gastroenterologists, and all of them fully agreed that the procedure should be performed on the manikin before in the actual patient, and they all approved the model for undergraduate education. A total of 87 undergraduate medical students (56% male) individually performed the procedure in our simulator. Regarding the steps of the procedure, 80.5% identified the appropriate place for needle puncture and 75.9% proceeded with the Z or traction technique. An amount of 80.5% of the students were able to aspire the fluid and another 80.5% of students correctly performed the bandage at the end of the procedure. All the students fully agreed that simulated paracentesis training should be performed prior to performing the procedure on a real patient. CONCLUSION: The elaboration of a teaching model in paracentesis provided unique experience to authors and participants, allowing a visible correlation of the human anatomy with synthetic materials, deepening knowledge of this basic science and developing creative skills, which enhances clinical practice. There are no data on the use of paracentesis simulation models in Brazilian universities. However, the procedure is quite accomplished in health services and needs to be trained. The model described above was presented as qualified with low cost and easily reproducible.

RESUMO CONTEXTO: A paracentese é um procedimento médico de rotina bastante relevante na prática clínica. Devido à sua importância na assistência médica diária e seus riscos de complicações, o treino do procedimento é essencial em currículos médicos reconhecidos. OBJETIVO: Descrever a construção de um simulador de paracentese de baixo custo, destacando a percepção de estudantes sobre o seu uso para treinamento na graduação em Medicina. MÉTODOS: Um modelo de baixo custo foi desenvolvido pelo Programa de Educação Tutorial para treinamento de estudantes de Medicina durante três edições de um curso teórico-prático de procedimentos invasivos à beira do leito. Os autores construíram um modelo a partir de materiais comuns e de fácil acesso, como manequim comercial e suportes de madeira e plástico para representar o abdômen, tecido de couro sintético para a pele, esponja revestida com filme plástico para representar a parede abdominal e luvas de procedimento com água misturada com tinta para simular o líquido ascítico e outras estruturas abdominais. Para avaliar o modelo, aplicou-se um questionário semiestruturado com aspectos quantitativos e qualitativos para médicos especialistas e estudantes. RESULTADOS: O modelo para paracentese tem orçamento inicial de US$22.00 / R$70,00 para 30 simulações e US$16.00 / R$50,00 para cada 30 simulações adicionais. Foi testado por oito especialistas (clínico geral, cirurgião geral e gastroenterologista), dos quais quatro são gastroenterologistas, e todos concordaram plenamente que o procedimento deve ser realizado no manequim antes de ser feito no paciente real, e todos eles aprovaram o modelo para o ensino de graduação. Durante as edições do curso, um total de 87 estudantes de graduação em Medicina (56% homens) realizaram individualmente o procedimento. Em relação às etapas do procedimento, do total de alunos avaliados, 80,5% identificaram o local apropriado para a punção e 75,9% procederam com a técnica Z ou tração. Ao final, 80,5% dos alunos conseguiram aspirar ao conteúdo ascítico, com 80,5% realizando o curativo e finalizando o procedimento. Todos os alunos concordaram plenamente que o treinamento com paracentese simulada deve ser feito antes de se realizar o procedimento em um paciente real. CONCLUSÃO: A elaboração de um modelo de ensino em paracentese proporcionou experiência única a autores e participantes, permitindo uma visível correlação da anatomia humana com materiais sintéticos, aprofundando o conhecimento desta ciência básica e desenvolvendo habilidades criativas, o que potencializa a prática clínica. Não há dados sobre o uso de modelos de simulação de paracentese em universidades brasileiras. No entanto, o procedimento é bastante realizado nos serviços de saúde e precisa ser treinado. O modelo descrito acima foi apresentado como de qualidade, baixo custo e de fácil reprodutibilidade, sendo inédito no cenário da educação médica nacional, mostrando-se uma ferramenta complementar de ensino na graduação e preparando os alunos para o procedimento in vivo.

The Procedure Coordinator: A Resident-Driven Initiative to Increase Opportunity for Inpatient Procedures.

BACKGROUND: Training residents to become competent in common bedside procedures can be challenging. Some hospitals have attending physician-led procedure teams with oversight of all procedures to improve procedural training, but these teams require significant resources to establish and maintain. OBJECTIVE: We sought to improve resident procedural training by implementing a resident-run procedure team without routine attending involvement. METHODS: We created the role of a resident procedure coordinator (RPC). Interested residents on less time-intensive rotations voluntarily served as RPC. Medical providers in the hospital contacted the RPC through a designated pager when a bedside procedure was needed. A structured credentialing process, using direct observation and a procedure-specific checklist, was developed to determine residents' competence for completing procedures independently. Checklists were developed by the residency program and approved by institutional subspecialists. The service was implemented in June 2016 at an 850-bed academic medical center with 70 internal medicine and 32 medicine-pediatrics residents. The procedure service functioned without routine attending involvement. The impact was evaluated through resident procedure logs and surveys of residents and attending physicians. RESULTS: Compared with preimplementation procedure logs, there were substantial increases postimplementation in resident-performed procedures and the number of residents credentialed in paracenteses, thoracenteses, and lumbar punctures. Fifty-nine of 102 (58%) residents responded to the survey, with 42 (71%) reporting the initiative increased their ability to obtain procedural experience. Thirty-one of 36 (86%) attending respondents reported preferentially using the service. CONCLUSIONS: The RPC model increased resident procedural training opportunities using a structured sign-off process and an operationalized service.

Paracentesis Simulation: A Comprehensive Approach to Procedural Education.

Introduction: Structured procedural education and assessment of competency are growing needs for residency and fellowship programs. Simulation is a useful way to learn, experience, and practice procedural skills with competence. Paracentesis is a common procedure encountered in internal medicine. This educational resource for paracentesis education includes didactics, cases, and assessments to address cognitive skills, a simulation experience to address psychomotor procedural skills, and an entrustment-based assessment tool. Methods: Prior to the simulation, learners completed preprocedural didactics and self-assessments. Utilizing a paracentesis trainer, ultrasound, and paracentesis kit, the case of a 46-year-old male with ascites in need of a paracentesis was presented. During the simulation, learners initially performed a paracentesis step by step, with assistance and feedback from the case instructor. This was immediately followed by paracentesis without assistance, where the instructor evaluated the learners with an assessment tool encompassing a procedural checklist, global skill assessment scale, and entrustment scale. Afterwards, learners completed case-based reviews and returned to the simulation lab several months later to repeat an unassisted paracentesis. Results: The curriculum was used with internal medicine and medicine-pediatric residents of all training levels. To date, over 120 residents have completed the curriculum. Residents reported an increase in self-confidence and competence using ultrasound to identify ascites and performing a paracentesis. Learners provided positive feedback. Discussion: This curriculum offers the opportunity for both cognitive and psychomotor paracentesis education in a low-risk simulation environment. The comprehensive strategy with didactics, cases, and multiple simulations is designed to promote knowledge and skill retention.

THE OLD ONE TECHNIQUE IN A NEW STYLE: DEVELOPING PROCEDURAL SKILLS IN PARACENTESIS IN A LOW COST SIMULATOR MODEL.

BACKGROUND: Paracentesis is a routine medical procedure quite relevant in clinical practice. There are risks of complications related to paracentesis, so it is essential a proper trainee for the younger practicer. OBJECTIVE: The article describes the construction and the application of a low cost paracentesis simulator for undergraduate medical students and it also describes the perception of students about the simulator as well. METHODS: A low-cost model was developed by the Program of Tutorial Education for training medical students during three editions of an undergraduate theoretical-practical course of bedside invasive procedures. The authors constructed a model from very low-cost and easily accessible materials, such as commercial dummy plus wooden and plastic supports to represent the abdomen, synthetic leather fabric for the skin, upholstered sponge coated with plastic film to represent the abdominal wall and procedure gloves with water mixed with paint to simulate the ascitic fluid and other abdominal structures. One semi-structured form with quantitative and qualitative questions was applied for medical specialists and students in order to evaluate the paracentesis simulator. RESULTS: The paracentesis model has an initial cost of US$22.00 / R$70.00 for 30 simulations and US$16.00 / R$50.00 for every 30 additional simulations. It was tested by eight medical doctors, including clinical medicine, general surgeons and gastroenterologists, and all of them fully agreed that the procedure should be performed on the manikin before in the actual patient, and they all approved the model for undergraduate education. A total of 87 undergraduate medical students (56% male) individually performed the procedure in our simulator. Regarding the steps of the procedure, 80.5% identified the appropriate place for needle puncture and 75.9% proceeded with the Z or traction technique. An amount of 80.5% of the students were able to aspire the fluid and another 80.5% of students correctly performed the bandage at the end of the procedure. All the students fully agreed that simulated paracentesis training should be performed prior to performing the procedure on a real patient. CONCLUSION: The elaboration of a teaching model in paracentesis provided unique experience to authors and participants, allowing a visible correlation of the human anatomy with synthetic materials, deepening knowledge of this basic science and developing creative skills, which enhances clinical practice. There are no data on the use of paracentesis simulation models in Brazilian universities. However, the procedure is quite accomplished in health services and needs to be trained. The model described above was presented as qualified with low cost and easily reproducible.

A Novel Task Trainer for Penile Corpus Cavernosa Aspiration.

INTRODUCTION: Priapism is a rare yet time sensitive emergency with potentially significant morbidity. A novel task trainer was developed for corpus cavernosa aspiration and phenylephrine injection. The primary aim of this study was to assess model realism and usefulness for emergency medicine resident procedural education. Secondarily, an assessment of comfort level with the procedure before and after intervention was performed. METHODS: A priapism model containing corpus cavernosa and spongiosum analogs was constructed. The models and evaluation forms were pilot tested by faculty and then tested for realism and usefulness in a sample of 49 residents after a brief training session. Secondary end points included resident comfort with cavernosa aspiration before and after the session of the model on a visual analog scale. RESULTS: Eight faculty pilot tested the procedure model and evaluated it based on a 5-point scale. They unanimously felt that the model was realistic [mean = 4.4, 95% confidence interval (CI) = 3.8-5.0] and useful for resident education (mean = 4.8, 95% CI = 4.4-5.0). The model was then evaluated for realism and usefulness in 49 residents. The model was felt to be realistic (mean = 4.3, 95% CI = 4.0-4.5) and useful for resident education (mean = 4.6, 95% CI = 4.4-4.8). Residents also noted an improvement in comfort performing the procedure before and after simulation session with the mean visual analog scale rating increasing from 34.3 to 83.8 (P < 0.001). CONCLUSIONS: An easily constructed priapism task trainer was felt to be realistic and useful for resident education. Secondarily, use of the model in a simulation session can improve resident comfort in an important and infrequent procedure.

Core Competencies or a Competent Core? A Scoping Review and Realist Synthesis of Invasive Bedside Procedural Skills Training in Internal Medicine.

PURPOSE: Invasive bedside procedures are core competencies for internal medicine, yet no formal training guidelines exist. The authors conducted a scoping review and realist synthesis to characterize current training for lumbar puncture, arthrocentesis, paracentesis, thoracentesis, and central venous catheterization. They aimed to collate how educators justify using specific interventions, establish which interventions have the best evidence, and offer directions for future research and training. METHOD: The authors systematically searched Medline, Embase, the Cochrane Library, and ERIC through April 2015. Studies were screened in three phases; all reviews were performed independently and in duplicate. The authors extracted information on learner and patient demographics, study design and methodological quality, and details of training interventions and measured outcomes. A three-step realist synthesis was performed to synthesize findings on each study's context, mechanism, and outcome, and to identify a foundational training model. RESULTS: From an initial 6,671 studies, 149 studies were further reduced to 67 (45%) reporting sufficient information for realist synthesis. Analysis yielded four types of procedural skills training interventions. There was relative consistency across contexts and significant differences in mechanisms and outcomes across the four intervention types. The medical procedural service was identified as an adaptable foundational training model. CONCLUSIONS: The observed heterogeneity in procedural skills training implies that programs are not consistently developing residents who are competent in core procedures. The findings suggest that researchers in education and quality improvement will need to collaborate to design training that develops a "competent core" of proceduralists using simulation and clinical rotations.

Are we failing our trainees in providing opportunities to attain procedural confidence?

Practical procedures play a crucial role in clinical outcome. High proportions of Mersey trainees report a lack of procedural confidence despite the fact that the majority want to perform more procedures. Training has to be carefully analysed to address these shortcomings.

Specialties performing paracentesis procedures at university hospitals: implications for training and certification.

BACKGROUND: Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear. OBJECTIVE: To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs. DESIGN, SETTING, PATIENTS: Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals. EXPOSURE: Patients with liver disease who underwent inpatient paracentesis procedures. MEASUREMENTS: We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral. RESULTS: There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001). CONCLUSIONS: Internal medicine- and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs.

Educational quality of YouTube videos on knee arthrocentesis.

BACKGROUND: Knee arthrocentesis is a commonly performed diagnostic and therapeutic procedure in rheumatology and orthopedic surgery. Classic teaching of arthrocentesis skills relies on hands-on practice under supervision. Video-based online teaching is an increasingly utilized educational tool in higher and clinical education. YouTube is a popular video-sharing Web site that can be accessed as a teaching source. OBJECTIVE: The objective of this study was to assess the educational value of YouTube videos on knee arthrocentesis posted by health professionals and institutions during the period from 2008 to 2012. METHODS: The YouTube video database was systematically searched using 5 search terms related to knee arthrocentesis. Two independent clinical reviewers assessed videos for procedural technique and educational value using a 5-point global score, ranging from 1 = poor quality to 5 = excellent educational quality. As validated international guidelines are lacking, we used the guidelines of the Swiss Society of Rheumatology as criterion standard for the procedure. RESULTS: Of more than thousand findings, 13 videos met the inclusion criteria. Of those, 2 contained additional animated video material: one was purely animated, and one was a check list. The average length was 3.31 ± 2.28 minutes. The most popular video had 1388 hits per month. Our mean global score for educational value was 3.1 ± 1.0. Eight videos (62 %) were considered useful for teaching purposes. Use of a "no-touch" procedure, meaning that once disinfected the skin remains untouched before needle penetration, was present in all videos. Six videos (46%) demonstrated full sterile conditions. There was no clear preference of a medial (n = 8) versus lateral (n = 5) approach. CONCLUSIONS: A discreet number of YouTube videos on knee arthrocentesis appeared to be suitable for application in a Web-based format for medical students, fellows, and residents. The low-average mean global score for overall educational value suggests an improvement of future video-based instructional materials on YouTube would be necessary before regular use for teaching could be recommended.