Akhtar Saadia, Hwang Ula, Dickman Eitan, Nelson Bret P, Morrison Rolfe Sean, Todd Knox H
Department of Emergency Medicine, Beth Israel Medical Center, New York, New York.
J Emerg Med. 2013 Nov;45(5):726-30. doi: 10.1016/j.jemermed.2013.04.051. Epub 2013 Aug 30.
Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure.
We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session.
First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months.
A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency.
A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients.
髋部骨折是急诊科常见的疼痛病症。处于疼痛中的老年人通常接受的镇痛药物剂量不足，尤其是在拥挤的急诊科。麻醉医生已采用神经阻滞来帮助控制髋部骨折术后的疼痛。超声引导下使用神经刺激器提高了该操作的安全性。
我们开展了一项试点研究，以评估急诊医学（EM）住院医师在参加理论讲授和演示课程后有效实施该操作的能力。
来自三个城市培训项目的一年级EM住院医师接受了为期1小时的股神经阻滞（FNB）操作理论讲授和实践培训课程。使用书面预测试来评估基线知识；在培训课程结束后1个月和3个月再次进行测试（测试项目随机）。使用关键操作清单（通过模拟患者诊疗过程直接观察操作步骤）在培训课程后以及3个月后对住院医师进行评估。
最初共评估了38名EM住院医师。33人成功完成了1个月和3个月的书面测试评估；30人完成了所有书面和直接观察评估。书面预测试平均分数为66%（标准差9）；测试后为92%（标准差5），1个月时为74%（标准差8），3个月时为75%（标准差9）。初始培训后，38名住院医师中有37名（97%）通过直接观察确定在FNB操作中具备能力（完成19项关键操作中的≥15项）。3个月时，30名住院医师中有25名（83%）继续保持其初始关键操作技能的85%，30名中有3名（10%）操作熟练程度有所提高。
一个1小时的培训和演示模块使住院医师在执行与FNB相关的关键操作时具备了较高的能力水平；这些技能在3个月时得到了很好的保持。一项正在进行的研究将尝试将这种能力与对患者实施的操作相关联。
