Ruparel Raaj K, Laack Torrey A, Brahmbhatt Rushin D, Rowse Phillip G, Aho Johnathon M, AlJamal Yazan N, Kim Brian D, Morris David S, Farley David R, Campbell Ronna L
Department of Surgery, Mayo Clinic, Rochester, Minnesota.
Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota.
J Emerg Med. 2017 Jul;53(1):110-115. doi: 10.1016/j.jemermed.2017.02.016. Epub 2017 Apr 11.
Quality-improvement efforts at our institution have identified chest tube dislodgement as a preventable complication of tube thoracostomy. Because proper fixation techniques are not well described in the literature and are seldom formally taught, techniques vary among residents.
Our aim was to develop and test a framework for teaching and assessing chest tube securement.
A repeated-measures study design was used. At baseline, 19 emergency medicine residents (program years 1-3) placed and secured a chest tube in a cadaver. After a 45-min proficiency-based teaching session using a low-cost chest tube simulator (approximate cost, $5), each resident again placed and secured a chest tube in a cadaver, followed by 3-month retention testing. All securements were evaluated by two raters using a four-point checklist and a five-point global assessment scale (GAS). The checklist addressed suture selection, tying knots down to the tube, wound approximation, and tube displacement relative to skin.
After the initial educational intervention, median scores for the group improved significantly over baseline for the GAS (p < 0.001), checklist (p < 0.001), and amount of displacement (p = 0.01). At 3 months, GAS, checklist, and displacement scores did not differ significantly from the immediate post-test scores. Inter-rater reliability was substantial, with weighted κ values of .77 for the GAS and .70 for the checklist.
Quality of chest tube securement by emergency medicine residents can be significantly improved with an inexpensive chest tube simulator and a brief workshop. The four-point checklist served as a reliable and effective means for teaching and assessing chest tube securement.
我们机构的质量改进工作已将胸管移位确定为胸腔闭式引流术的一种可预防并发症。由于文献中对正确的固定技术描述不足，且很少进行正式教学，住院医师之间的技术存在差异。
我们的目标是开发并测试一种胸管固定的教学和评估框架。
采用重复测量研究设计。在基线时，19名急诊医学住院医师（第1 - 3学年）在一具尸体上放置并固定胸管。在使用低成本胸管模拟器（约5美元）进行45分钟基于熟练度的教学课程后，每位住院医师再次在一具尸体上放置并固定胸管，随后进行3个月的保留测试。所有固定操作由两名评估者使用四点检查表和五点整体评估量表（GAS）进行评估。检查表涉及缝线选择、在胸管上打结、伤口闭合以及胸管相对于皮肤的移位情况。
经过最初的教育干预后，该组在GAS（p < 0.001）、检查表（p < 0.001）和移位量（p = 0.01）方面的中位数得分较基线有显著提高。在3个月时，GAS、检查表和移位得分与即时测试后的得分相比无显著差异。评估者间信度较高，GAS的加权κ值为0.77，检查表的加权κ值为0.70。
使用廉价的胸管模拟器和简短的工作坊可显著提高急诊医学住院医师胸管固定的质量。四点检查表是教学和评估胸管固定的可靠且有效手段。
