Development of a Chief Resident Medical Procedure Service: a 10-Year Experience

We have demonstrated that 4th-year IM chief residents trained in ultrasound-guided procedures can safely lead an MPS with high procedure success rates and low complication rates. The procedure rotation was highly rated by interns who valued the training and supervision received by the chief residents. Clinical outcomes of our chief resident–led MPS were comparable to those reported in a 2021 meta-analysis of 8 predominantly attending physician–led procedure services that reported pooled success and complication rates of 94.7% and 2.1%, respectively.2 Similarly, our major complication rate of 0.6% was comparable to a recent MPS study reporting 0.8%.5

Our success rate of 76% for lumbar puncture was lower than that of paracentesis and thoracentesis, but reassuringly this outcome is comparable to two recent studies of MPS’s supervised by attending physicians which reported success rates ranging from 73 to 79.4%.5,10 Factors associated with failure to obtain cerebrospinal fluid, including obesity and prior spinal surgery, were frequently encountered in our patient population.10,11 Also, in our local hospital practices, it is typically recommended that the primary teams or the MPS evaluate and attempt to perform a lumbar puncture at the bedside prior to referring the patient to interventional radiology. Therefore, attempting lumbar punctures on patients with known characteristics lowering the probability of a successful procedure, such as morbid obesity or prior spinal surgery, likely contributed to the MPS’s lower success rate. For central venous catheterization and arthrocentesis, the lower relative success rates may have been driven by the low volume of these procedures. A sufficient volume of procedures is essential to enhance procedural skills and achieve favorable success and complication rates.4,12,13,14

The structure and curricular components of our MPS are similar to other attending physician–led MPS’s with respect to availability during weekdays and business hours only, types of procedures performed, and inclusion of both didactic and simulation-based training methods.1,3,15,16,17,18 However, a chief resident–led MPS is a novel approach to overcome the limited availability of experienced attending physicians who can serve as proceduralists to establish an MPS. Our unique staffing model may allow other IM residency programs to gain the potential benefits of creating an MPS which include improvements in procedural volume, patient throughput, procedural education of trainees, and healthcare costs.3 Most MPS’s described in the literature include hospitalists, pulmonologists, or critical care attendings as the supervising proceduralists.3 One notable exception is the study by Gorgone et al. which described an MPS independently run by residents who perform most procedures unsupervised, but could seek faculty supervision when needed.4 Our MPS differed in that our 4th-year chief residents received junior faculty appointments and supervised nearly all intern-performed procedures without additional faculty support.

Strengths of our study include a high number of procedures performed (n=4465) and long study duration (>10 years) compared to prior studies ranging from 2 to 60 months.3 Our study also provides quantitative and qualitative data on MPS complications by procedure type, as few MPS studies have previously provided this data.1,2,18,19,20

Our study has several limitations. First, as a single-center study our results may have limited external validity to other healthcare systems. Second, though the complication rates for arthrocentesis and central venous catheterization were low, these results may not be reproducible given the low number of these procedures performed. However, we chose to include these data as they may guide resource allocation for training and equipment for institutions seeking to establish an MPS. Given the relatively infrequent consults for arthrocentesis and central line placement, some procedure services may choose to prioritize the more common procedures, namely paracentesis, thoracentesis, and lumbar puncture, especially when starting a new service. Third, lack of standardized definitions for certain procedural complications, such as pain, may have led to variability in reporting by the MPS team. Further, though scheduled time was provided for procedure log data entry and the MPS director reviewed the procedure log up to twice per month to reconcile data, we cannot rule out the possibility of incomplete or missing data which may affect the results. We also cannot rule out the possibility of bias by the participants to underreport complications, but this is less likely because all data were originally collected for quality assurance and performance improvement.21 Finally, we followed patients for 24 h for delayed complications, whereas some studies monitored patients for more than 24 h.6,18,20 While 24 h is likely sufficient to detect most delayed complications, this was likely insufficient time to detect central line–associated blood stream infections, and this complication was not explicitly tracked.

In conclusion, an MPS led by 4th-year IM chief residents is a practical yet safe approach for IM residency programs to establish an MPS when attending physicians with expertise in ultrasound-guided procedures are not available. Our chief resident–led MPS had procedure success and complication rates similar to attending physician–led procedure services reported in the literature. Future studies shall investigate health services outcomes, such as impact on length of stay, costs, and patient experience, when procedures are performed by a chief resident–led MPS versus traditional approaches.

留言 (0)

沒有登入
gif