One trend working in favor of more hospitalist-led bedside procedures is the growing use of technology, particularly simulation models and ultrasound guidance. Simulators are “invaluable” teaching tools, says David Lichtman, PA, director of the Johns Hopkins Central Procedure Service in Baltimore, Md.
“They’re easy. They’re inexpensive. You can poke them and poke them and poke them and they don’t scream. They’re not in pain,” he says. “ You’re not going to wind up hurting anybody by practicing on those simulation mannequins, simulators in the labs, and computer-based models.”
Lichtman says he’d also like to use Google Glass to create better training videos for central line placement from the point of view of the practitioner, particularly for cases that aren’t by the book.
As part of its procedure training, Northwestern University in Chicago includes simulation-based mastery learning, which assesses practitioners after a rigorous training regimen; those who don’t perform well receive more training and practice until they can meet the necessary testing benchmarks. The method ensures that on a simulator, everyone can perform the procedure competently. And in actual patient care, the strategy has been linked to decreased central line-related complications.5
Sally Wang, MD, FHM, director of procedure education at Brigham and Women’s Hospital and a clinical instructor at Harvard Medical School in Boston, calls simulation training “absolutely necessary.” Hospitals that haven’t built their own simulation center, she says, are actively seeking out other simulation centers for training purposes. Checklists, proficiency guidelines, and more realistic simulation models are all being incorporated into training programs well before trainees start practicing on live patients, she says, as part of the necessary shift away from the old “see one, do one, teach one” model.
Beyond basic but effective “task trainers,” more advanced simulator models have heads that turn, anatomy similar to that of a live patient, and even “skin” that permits the use of ultrasound.
Even low-fidelity simulation training can be enormously helpful if it allows a provider to visualize a procedure’s steps before performing them on a patient, says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California San Francisco. And research suggests that a significant amount of up-front simulation training can decrease the number of real-life procedures needed to achieve competency. The benefits of training fade over time, however, and accessing the sustained practice and simulation opportunities needed to maintain competencies could be a “big challenge,” she says.
Ultrasound is providing another potent—and increasingly portable—tool. Ultrasound guidance is now the standard of care for central lines, with paracentesis and thoracentesis following close behind. Imaging is used somewhat less often for lumbar puncture, but that too is trending in the direction of more ultrasound guidance. “I know of no interventional radiologist who would say that it’s OK on themselves or a family member to have any of these procedures done that weren’t imaging guided, because we’ve seen the outcomes when they’re not,” says Robert L. Vogelzang, MD, FSIR, professor of radiology at Northwestern University Feinberg School of Medicine in Chicago.
Enhanced safety, however, depends upon understanding how to use the tool and how to interpret the results. “The reality is, ultrasounds are great, but if you don’t know how to interpret the data, that information is worse than no information, and that can lead to worsening outcomes,” Lichtman says. A paracentesis that fails to draw any fluid from a patient’s belly, for example, may be due to the misreading of an ultrasound that actually indicated an absence of fluid. And accidentally sticking the needle into a patient’s bowel could cause a perforation or peritonitis.
Some institutions are now incorporating basic ultrasound training into medical school programs.
“It is going to be the way of the future,” Dr. Wang says. “I really think that we’re going to use ultrasound to replace the stethoscope even.” Doctors may instead perform ultrasound with probe-equipped smartphones.
Even then, she says, the technique will be effective only with the kind of advanced training that lets doctors know what they’re visualizing and whether they’re in an artery or vein, for example.
Amid mounting evidence that ultrasound use can improve outcomes, Melissa Tukey, MD, MSc, a pulmonology critical care physician at Lahey Clinic in Burlington, Mass., cautions that there may be other downsides. Cost, for example, may be a limiting factor for some hospitals. Another is physician training and comfort: Although younger physicians have grown up with the technology, she says, many older physicians lack exposure to and comfort using it. “Because ultrasound is now mandated as a quality measure for a number of the procedures, it really limits, by default, the performance of those procedures to a generation of clinicians that’s been trained in ultrasound,” she says.
Hospitals, then, need to ensure that an embrace of ultrasound technology doesn’t leave older physicians out in the cold.