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At least 343 records · Page 19Linked to original sources

PubMed2001

Procedures performed by pediatric transport nurses: how "advanced" is the practice?

INTRODUCTION: Pediatric interfacility transport teams often rely on advanced practice nurses as primary care providers. These individuals may be required to transport patients without the presence of a physician. There is, however, little information in the medical literature regarding how frequently advanced practice transport nurses perform advanced procedures, how often these procedures are successfully performed, and the rate of complications associated with nurse-performed procedures. PURPOSE: The purpose of this study was to determine how frequently advanced practice transport nurses were called on to perform advanced procedures and to determine the nurses' procedural success and complication rates. DESIGN: Prospective convenience sample of consecutive pediatric interfacility transports. METHODS: Transport nurses collected data on 336 pediatric interfacility transports that were performed during a 4-month period beginning in May 1997. All patient transports occurring during the study period were included. Data regarding procedures were recorded on data collection sheets. This data included the type of procedure performed, the outcome of the procedure, and the complications associated with the procedure. The number of attempts required to successfully complete the procedure was not recorded. During or after the patient's hospitalization, the medical record was reviewed to identify potential complications related to the transport that may not have been recorded on the data collection sheet. RESULTS: Nurses performed 95.2% of transports without the presence of a physician. Twenty-six patients (8.8%) required advanced procedures. Nurses performed eight tracheal intubations. Personnel at the referring hospital performed the remaining procedures. All tracheal intubations by transport nurses were successful. There were no complications related to these procedures. All patients were transported to the receiving hospital without incident. CONCLUSIONS: Although they had considerable training for advanced procedures, the transport nurses rarely used these skills. All tracheal intubations performed by transport nurses were successful, and there were no adverse consequences related to intubation by a transport nurse.

Ambulances↗

PubMed2000

Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey.

OBJECTIVE: Although the equimolecular mixture of oxygen and nitrous oxide (EMONO) seems a good choice to relieve procedure-related pain in children, it has not been accepted everywhere. In France, the rapid spread of its use has elicited suspicion and doubts regarding its safety. To assess the use and the safety of this gas mixture in the pediatric settings in France, we conducted a national survey. METHODOLOGY: Centers that had accepted a nation- wide invitation to participate in the survey filled out a questionnaire after each EMONO administration during a 2-month study. Procedure and inhalation characteristics, as well as pain evaluations and side effects, were reported. RESULTS: One thousand nineteen EMONO inhalations from 31 centers that agreed to participate in this 2-month survey were analyzed. Median (range) age was 6.4 (0-18) years. Four percent (46) of children were 12 months old or younger, 29% (295) were 5 years old or younger, 45% (459) were 6 to 10 years old, and 26% (265) were older than 10 years of age. The procedures performed with EMONO inhalation were: lumbar punctures (286), bone marrow aspirations (BMA; 231), laceration repairs (215), minor procedures (75), minor surgery (53), punctures (49), fractures (45), dental care (43), and pulmonary endoscopy (22). Nine percent of procedures were undertaken without the presence of a physician; the child being observed only by the attending nurse. A drug association was noted in 182 (17.9%) of procedures: midazolam (63%), acetaminophen (18%), nalbuphine (8.5%), hydroxyzine (5%), flunitrazepam (2%), chlorazepate (2%), morphine (1%), and lorazepam (.5%). EMLA cream (Astra) was applied in 98.6% of lumbar punctures, 93.7% of BMA, and 54.2% of punctures including lymph nodes, hematoma, or renal biopsies. Lidocaine infiltration was performed in 51% of minor surgery procedures, 40% of laceration repairs, and 28% of BMA. The inhalation system included a whistle, a scented mask, and a nonrebreathing respiratory valve in 48.9%, 71.2%, and 78.3% of the patients, respectively. Initial physical restraint was needed in 18. 2% of all the patients. Inhalation refusal was noted in 129 (12.7%) children; of these, 53 had an alternative method of analgesia (EMLA or lidocaine infiltration), 15 had no other analgesia, and in the remaining 61, EMONO inhalation was maintained against the child's will. Median (interquartile) inhalation length was 4 (3-5) minutes before starting the procedure and 6 (6-15) minutes for the total inhalation. Median (interquartile) procedural pain evaluations were 9 (0-30) for children on a 0 to 100 visual analog scale, 1 (0-3) for both nurses and parents on a 0 to 10 numerical scale. Median (interquartile) procedural pain as evaluated by nurses for the 3 most frequent procedures were 0 (0-2) for lumbar punctures, 2 (0-4) for bone marrow aspiration, and 2 (0-4) for laceration repair. Comparison of pain assessed by nurses in children 3 years old or younger and those older than 3 years of age showed a median (range) score of 2 (0-10) versus 1 (0-10), respectively. Pain self-assessment was completed in 647 children 6 years of age or older. Median (interquartile) children pain assessments were as follows: lumbar puncture (5; 0-20), bone marrow aspiration (12.5; 0-40), laceration repair (12; 0-40), minor procedures (18; 0-32), minor surgery (10; 0-35), punctures (0; 0-18), fracture (15; 0-30), dental care (20; 0-40), and pulmonary endoscopy (15; 0-30). Ninety-three percent of the 647 children who were able to answer the question said they would accept EMONO analgesia if a new procedure were to be performed. Behavioral reactions during procedures varied with age of the child; cry was observed in 44.1%, 24.4%, 12.9%, and 11.2% of children 3 years or younger, 4 to 6 years, 7 to 10 years, and 11 years or older, respectively. Physical restraint was necessary in 34.2%, 22%, 13.5%, and 8.4% of children aged 3 years or younger, 4 to 6 years, 7 to 10 years, and 11 years or old

Administration, Inhalation↗

PubMed1990

Procedural skills of practicing gastroenterologists. A national survey of 700 members of the American College of Physicians.

OBJECTIVE: To find which procedures gastroenterologists do in their practice, where they learned the procedures, and what training they recommend to achieve and maintain competence in each. DESIGN: Mailed survey. PARTICIPANTS: A random sample of 700 gastroenterologists who were members of the American College of Physicians, of whom 510 (73%) responded. RESULTS: Gastroenterologists did a median of 27 of the 40 gastroenterology procedures and 3 of the 16 general medicine procedures. A larger number of different procedures was done by those who were board certified in gastroenterology, spent more than 60 hours per week in patient care, graduated after 1969, or practiced in a university setting, a hospital with 250 to 500 beds, or a group limited to gastroenterologists. The majority of respondents had done each of the three most commonly done procedures 200 or more times in the previous year. For 10 procedures studied in detail, the majority had done 9 of the 10 in the past year at least as often as the median recommendation for maintaining competence. The number of procedures recommended to achieve and maintain competence differed little by the age, type of practice, and gastroenterology board certification status of the respondent. For most procedures, the range of recommendations was broad, but the median numbers agreed with other published recommendations. Respondents learned 31% of procedures after they had completed training. The earlier their training, the more likely they had learned the procedure in practice. CONCLUSIONS: Gastroenterologists do many different procedures, and this number is influenced by how recently they were trained and the nature of their practice. Respondents learned nearly one third of the procedures they do after they had completed training. It is an important and continuing challenge for the profession to assure that physicians learn and maintain these procedural skills at the highest level of proficiency.

Clinical Competence↗

PubMed1999

Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures.

STUDY OBJECTIVE: To compare patient and practitioner assessments of pain associated with commonly performed emergency department procedures and use of anesthetics before these procedures. METHODS: This was a prospective, observational, cross-sectional study conducted at a university-based ED with a convenience sample of ED patients. Research assistants recorded the procedure performed and historical and demographic information on standardized data collection instruments. After each procedure, both the patient and practitioner independently recorded assessments of patient pain on a 100-mm visual analog scale (VAS). Use of preprocedure anesthetics and patient preferences regarding their use were also identified. Categorical variables were analyzed by chi(2) tests. Patient and practitioner VAS scores were compared using a paired t test; alpha was preset at .05. Correlation coefficients were calculated to assess correlation between patient and practitioner pain scores. RESULTS: A total of 1,171 procedures were evaluated for the 15 most common procedures performed. The mean patient age was 42.8+/-18.7 years and 46.1% were male. Overall, the mean patient VAS was 20.8 mm+/-25.1 mm; the mean practitioner VAS was 23.5 mm+/-20.3 mm. The mean difference between groups was 3.0 mm (95% confidence interval [CI], 1.3 to 4.1). Correlation between patient and practitioner pain scores for individual procedures was poor to fair (r=.26 to.68). The most painful procedures according to patients in descending order were nasogastric intubation, abscess drainage, fracture reduction, and urethral catheterization. Local anesthetics were administered in 12.8% of procedures yet would be requested before similar future procedures by 17.1% of patients. Patients who would choose local anesthetics in the future gave higher pain scores than those who would not (43.3 mm versus 16.3 mm; mean difference=27.0 mm, 95% CI, 22.2 to 31.8 mm). CONCLUSION: The most painful procedures for ED patients were nasogastric intubation, incision and drainage of abscesses, fracture reduction, and urethral catheterization. Although practitioners also identified these procedures as most painful, the correlation between patient and practitioner pain assessments in individual patients was highly variable. Overall use of anesthetics before these procedures was low. Practitioners should be attentive to their patients' individual anesthetic needs before performing painful procedures.

Adult↗

PubMed2005

Defining core procedure skills for Canadian family medicine training.

OBJECTIVE: To create a list of core and enhanced procedures suitable for family medicine training. DESIGN: Mailed or e-mailed survey using a Delphi technique. SETTING: Randomly selected family physician practices across Canada. PARTICIPANTS: Family physicians from urban, small-town, and rural practice locations and academic family physicians. All were experienced family physicians with from 3 to 36 years in practice. INTERVENTIONS: Participant physicians were asked to rate each of 158 procedures as to whether they would expect a graduate from a Canadian family practice training program to have learned and be capable of performing that procedure in their own community. In a second survey, participants were asked to verify the core and enhanced procedures lists produced from the first survey. MAIN OUTCOME MEASURES: Physicians' opinions about a comprehensive list of skills. RESULTS: Twenty-two physicians responded to the first survey (92% response rate) and 14 to the second (58% response rate). Sixty-five core procedures and 15 enhanced procedures were identified in the surveys. More procedures were ranked on the core list and were performed by rural and small-town physicians than by urban physicians. Physicians' agreement with placement of procedures on the core list ranged from 55% to 100% and of procedures on the enhanced list from 50% to 64%. Fifty-five of the procedures on the core list had agreement from more than 70% of participants. CONCLUSION: Procedure lists represent the opinions of Canadian family physicians about the importance of specific procedure skills for new family physicians in their communities. Procedure lists will be helpful for family medicine training programs to evaluate and refine their teaching of procedure skills.

Canada↗

PubMed2004

Patient injuries from surgical procedures performed in medical offices: three years of Florida data.

BACKGROUND: Many state medical boards and legislatures are in the process of developing regulations that restrict procedures in the office setting with the intention of enhancing patient safety. The highest quality data in existence on office procedure adverse incidents have been collected by the state of Florida. OBJECTIVE: The objective was to determine and analyze the nature of surgical incidents in office-based settings using 3 years of Florida data from March 2000 to March 2003. METHODS: An incidence study with prospective data collection was performed. Individual reports that resulted in death or a hospital transfer were further investigated by determining the reporting physician's board certification status, hospital privilege status (excluding procedure specific operating room privileges), and office accreditation status. RESULTS: In 3 years there were 13 procedure-related deaths and 43 procedure-related complications that resulted in a hospital transfer. Seven of the 13 deaths involved elective cosmetic procedures, 5 of which were performed under general anesthesia and 2 of which were performed with intravenous sedation anesthesia. Forty-two percent of the offices reporting deaths and 50% of the offices reporting procedural incidents that resulted in a hospital transfer were accredited by an independent accreditation agency. Ninety-six percent of physicians reporting surgical incidents were board-certified, and all had hospital privileges. CONCLUSIONS: Restrictions on office procedures for medically necessary procedures, such as requiring office accreditation, board certification, and hospital privileges, would have little effect on overall safety of surgical procedures. These data also show that the greatest danger to patients lies not with surgical procedures in office-based settings per se, but with cosmetic procedures that are performed in office-based settings, particularly when under general anesthesia. Our conclusions are dramatically different from those of a recent study, which claimed a 12-fold increased risk of death for procedures in the office setting.

Ambulatory Surgical Procedures↗

PubMed2000

A comparative study of two procedures for repair of involutional lower lid entropion.

OBJECTIVE: The study compares the use of Jones' retractor plication and the Wies procedure as a primary procedure for the repair of involutional lower lid entropion in the absence of horizontal lid shortening. DESIGN: Retrospective case series comparison. PARTICIPANTS: One hundred two cases with at least 6 months follow-up after primary surgery for involutional lower lid entropion performed between 1993 and 1996. INTERVENTIONS: Two groups were compared: Jones' retractor plication was performed in one group and the Wies procedure in the other; neither group had horizontal shortening of the lower eyelid. MAIN OUTCOME MEASURES: The rates of cure, recurrence, and overcorrection of the lower lid entropion. RESULTS: Jones' retractor plication was performed in 37 (36%) patients and the Wies procedure in 65 (64%). Two of the 37 (5%) Jones cases had recurrent entropion develop, both at 31 months after surgery, compared with 1 1 of 65 (17%) recurrences after the Wies procedure (P = 0.81); recurrence after Wies procedure was earlier, at a median of 6 months after surgery. There were 20 of 65 (31 %) overcorrections after the Wies procedure and 4 of 37 (11 %) after the Jones procedure (P < 0.02); one quarter of each group required secondary repair of the overcorrection (5 of 20 after failed Wies procedure; 25% after failed Jones procedure). Overall, there were 6 of 37 (16%) unsatisfactory results after the Jones procedure in contrast to 31 of 65 (48%) after the Wies procedure (P < 0.001). CONCLUSIONS: These data provide strong evidence (P < 0.001) that, in the absence of horizontal shortening of the lower eyelid, a successful outcome is more likely after Jones retractor plication than after the Wies procedure.

Aged↗

PubMed1997

Procedures for skin diseases performed by physicians in 1993 and 1994: analysis of data from the National Ambulatory Medical Care Survey.

BACKGROUND: The provision of ambulatory dermatologic procedural care is not well characterized. OBJECTIVE: Our purpose was to determine the frequency that different cutaneous procedures are performed by different physician specialties and the diagnoses corresponding to these procedures. METHODS: Outpatient dermatologic procedures recorded in the 1993 and 1994 National Ambulatory Medical Care Survey were analyzed. To define dermatologic procedures and diagnoses, the International Classification of Diseases diagnosis and procedure codes were identified that related to the skin and subcutaneous tissues. Sampling weights were applied to achieve the nationally representative estimates. RESULTS: During 1993 and 1994, an estimated 37 million dermatologic procedures were performed. Most were performed by dermatologists (69%) and by family and general practice physicians (15%). A single procedure, "Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue," constituted 65% of all of the dermatologic procedures. UV light treatments, ambulatory microscopic examination of skin specimens, and acne surgical procedures were performed almost exclusively by dermatologists. Most skin biopsies (82%) and excision/destruction procedures (71%) were performed by dermatologists. Actinic keratoses and viral warts accounted for 25% of all cutaneous dermatologic diagnoses treated. CONCLUSION: Dermatologists have far more experience performing skin biopsies and excision/destruction procedures than other physicians. Cost containment efforts that deny coverage for treatment of actinic keratoses and viral warts would affect a significant portion of cutaneous procedures.

Adult↗

PubMed2005

Assessment of the onset and persistence of amnesia during procedural sedation with propofol.

OBJECTIVES: To assess patients' ability to repeat and recall words presented to them while undergoing procedural sedation with propofol, and correlate their recall with their level of awareness as measured by bispectral index (BIS) monitoring. METHODS: This was a prospective, single-intervention study of consenting adult patients undergoing procedural sedation with propofol between December 28, 2002, and October 31, 2003. BIS monitoring was initiated starting 3 minutes before the procedure and continuing until the patient had regained baseline mental status. At 1-minute intervals during the procedural sedation, until the patient regained baseline mental status at the end of the procedure, a word from a standardized list was read aloud, and the patient was asked to immediately repeat the word to the investigator. The BIS score at the time the word was read and the patient's ability to repeat the word were recorded. After the procedure, the patient was asked to state all of the words from the list that he or she could recall, and to identify the last word recalled from prior to the start of the procedure and the first word recalled from after the procedure was completed. RESULTS: Seventy-five consenting patients were enrolled; one patient was excluded from data analysis for a protocol violation. No serious adverse events were noted during the procedural sedations. The mean (+/-standard deviation) time of data collection was 16.4 minutes (+/-7.1; range 5 to 34 minutes). The mean initial (preprocedure) BIS score was 97.1 (+/-2.3; range 92 to 99). The mean lowest BIS score occurring during these procedural sedations was 66.9 (+/-14.4; range 33 to 91). The mean lowest BIS score corresponding to the ability of the patient to immediately repeat words read from the list was 77.1 (95% CI = 74.3 to 80.0). The mean highest BIS score corresponding to the inability to repeat words was 81.5 (95% CI = 78.1 to 84.8). The mean BIS score corresponding to the last word recalled from prior to the initiation of the sedation was 96.7 (+/-2.4; range 84 to 98). The mean BIS score corresponding to the first word recalled after the procedure was completed was 91.2 (95% CI = 88.1 to 94.3). All patients recalled at least one word that had been read to them during the protocol. The mean lowest BIS score for any recalled word was 91.5 (+/-11.1; range 79 to 98), and no words were recalled when the corresponding BIS score was less than 90. CONCLUSIONS: There is a range of BIS scores during which sedated patients are able to repeat words read to them but are not able to subsequently recall these words. Furthermore, patients had no recall of words repeated prior to procedural sedation in BIS ranges associated with recall after procedural sedation, suggestive of retrograde amnesia.

Adult↗

PubMedDate not supplied

Osteoplastic flap versus modified endoscopic Lothrop procedure in patients with frontal sinus disease.

The aim of the present study was to review the clinical results of osteoplastic flap procedure with abdominal fat obliteration and modified endoscopic Lothrop procedure. Charts of patients with frontal sinus disease who underwent osteoplastic flap procedure with abdominal fat obliteration or modified endoscopic Lothrop procedure were retrospectively reviewed. Forty-three patients with frontal sinus disease underwent osteoplastic flap procedure with abdominal fat obliteration. Frontal sinus disease was chronic sinusitis in 21, mucocele in 18, and papilloma in four. None of the patients had recurrence within 3 to 12 years follow-up period. Six patients had decreased forehead sensation, one had a CSF leak, and one had loss of the fat graft. Fifteen patients with chronic frontal sinusitis underwent modified endoscopic Lothrop procedure. The follow-up period ranged from 0.5 to 2.5 years. Two patients had recurrence of disease 2 and 6 months after surgery and required osteoplastic flap. In patients with chronic frontal sinusitis, both procedures achieved good relief of symptoms; however, follow-up time of modified endoscopic Lothrop procedure was smaller than that of osteoplastic flap procedure. In conclusion, osteoplastic flap procedure with abdominal fat obliteration provides successful treatment in patients with frontal chronic sinusitis, mucocele, or papilloma. Modified endoscopic Lothrop procedure achieves the relief of symptoms in patients with chronic frontal sinusitis. With the future availability of long term follow-up results, modified endoscopic Lothrop procedure may reduce the number of osteoplastic flap procedures in patients with chronic frontal sinusitis.

Adult↗

PubMed1996

Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgical procedures.

Resource allocation, including manpower and other expenses, have limited the evolution of minimally invasive surgical procedures to provide humanism and to improve surgical care for patients. Robotic enhancement has been proposed as a mechanism to improve the cost-benefit relationship for patients. To this end, we have used the robotic arm enhancement to minimize resource and personnel utilization during minimally invasive procedures. Phase I of our study has included the use of the robotic arm in 24 laparoscopic hernia repairs, cholecystectomies, and nissen fundoplications with the surgeon as a solo surgeon, i.e., the primary surgeon is the only participant in the operative sterile field. The scrub nurse did not participate in the procedures. During this study, there were no technical mishaps, no complications related to the solo surgeon-robotic arm concept, and the operative times were statistically similar to equivalent procedures utilizing multiple personnel. The hernia repair is least complex and most amenable to solo surgery due to the use of only three access ports; cholecystectomy occasionally requires four access ports increasing its complexity to a measurable degree. Nissen fundoplication, however, requires five access ports and proved to be the most complex of the procedures to adapt successfully to solo surgery utilizing robotic arm enhancement. Phase II of our study has involved the use of a combination of technologically complex and sophisticated technology to improve outcomes in complex laparoscopic procedures. The head-mounted display, the robotic arm, and the harmonic scalpel have been used in 140 complex minimally invasive procedures; the procedures were laparoscopic spine surgery (24 cases), laparoscopic gastric surgery (28 cases), and laparoscopic colon resection (88 cases). The use of these sophisticated technologies added safety, improved versatility, and did not increase the length of the operative procedures. The use of multiple technologies had an additive effect on the benefits. There were no experiences in which the technologies contributed to a technical complication or an adverse result for the patients. However, the successful use of these technologies requires an in depth educational experience for the surgeon and for the operating room team. In a further effort to improve efficiency and control of the visual fields during minimally invasive surgery, we have implemented a prototype voice activation, head-directed control, and instrument tracking by robotic arm enhancement in order to control the visual field through computer programming. Prototype voice activation and deactivation also allows instruments to be used in the visual field for the surgical procedure while not being used for tracking of the visual field. Tracking with the instrument utilizing a color-coded tracking system, and the head-directed control system have both been 100% effective in our hands, have not induced errors in technical performance of procedures, and have shortened the time required for performance of specific procedural tasks. Further, this process improves versatility for the surgeon, increases concentration, reduces fatigue and does not interfere with the position of the surgeon. Areas for improvement which have been observed utilizing these techniques are (1) the use of appropriate and consistent voice activation terminology, (2) the proper positioning of the instrument tracking unit in the most appropriate locations on the video screen and on the instrument within the visual field, and (3) the appropriate use of head-directed control of the robotic arm. We have concluded from these experiences that the robotic technology will continue to reduce costs and minimize risk for patients undergoing minimally invasive surgical procedures; moreover, safety, versatility, and diminished use of resources will accrue utilizing the additive benefit of sequential sophisticated technologies requiring a simultaneous educational

Animals↗

PubMed1993

Ripstein procedure is an effective treatment for rectal prolapse without constipation.

The operation of choice for complete rectal prolapse is controversial. We reviewed 169 patients undergoing 185 surgical procedures for rectal prolapse over a 27-year period. The most common surgical procedure employed was the Ripstein procedure (n = 142) and is the focus of this report. Other surgical procedures used included resection rectopexy (n = 18), anterior resection (n = 7), Altemeier's (n = 9), Delorme's (n = 2), and anal encirclement (n = 7). The median age was 59 years (range, 12-94 years), and the female-to-male ratio was 5:1. The incidence of fecal incontinence, solitary rectal ulcer syndrome, and prior surgery elsewhere for rectal prolapse was 40 percent, 12 percent, and 19 percent, respectively. Operative mortality was 0.6 percent; morbidity was 16 percent. Median follow-up was 4.2 years (range, 1-15 years). Complete recurrence of prolapse after the Ripstein procedure was 8 percent; one-third of these patients recurred 3 to 14 years after surgery. Fecal incontinence improved after the Ripstein procedure or resection rectopexy in about half the patients. Persistence of prior constipation was more common after the Ripstein procedure than after resection rectopexy (57 percent vs. 17 percent; P = 0.03, chi-squared). Fifteen patients developed constipation for the first time after the Ripstein procedure. About one in three patients, irrespective of surgical procedures, remained dissatisfied with the final outcome despite anatomic correction of the prolapse. The Ripstein procedure has proven to be a safe procedure with good anatomic repair of the prolapse and may improve continence. In the presence of constipation, procedures other than the Ripstein procedure may be preferable.

Adolescent↗

PubMed2006

Beyond the comfort zone: residents assess their comfort performing inpatient medical procedures.

PURPOSE: Resident physicians learn to perform inpatient bedside procedures in a manner that is neither standardized nor rigorous. As a result, residents may be unskilled and uncomfortable performing procedures. This study characterizes residents' comfort performing medical procedures and identifies factors associated with lack of comfort. SUBJECTS: Study subjects were internal medicine resident physicians who performed one of four medical procedures (central line, lumbar puncture, paracentesis, or thoracentesis) on adult medical inpatients between July 1, 2003, and June 30, 2004. METHODS: This prospective cohort study was conducted at a 556-bed Boston teaching hospital. Resident physicians evaluated their comfort with 9 aspects of 4 medical procedures, recording this information in an electronic log. We also abstracted operator characteristics and patient demographic data. We analyzed residents' comfort with each aspect of the procedure and defined "overall comfort" as comfort with each of the 9 aspects. RESULTS: A majority of resident physicians reported lack of comfort with at least one aspect of the procedure. Residents reported lack of comfort with 37% of unsupervised procedures. They also reported lack of comfort with the prospect of managing complications in 35% of procedures. In the multivariable analysis, overall comfort was associated with the use of a dedicated medical procedure service (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.4) and inversely associated with postgraduate year 1 status (OR 0.3, CI 0.1-0.5), first time performing the procedure (OR 0.4, CI 0.2-0.8), thoracenteses (OR 0.4, CI 0.2-0.8), and emergent procedures (OR 0.6, CI 0.3-1.0). CONCLUSIONS: Many resident physicians are uncomfortable performing common bedside procedures. Experience and supervision mitigate some, but not all, discomfort.

Adult↗

PubMed1998

Additional procedures after the initial vitrectomy or tap-biopsy in the Endophthalmitis Vitrectomy Study.

OBJECTIVE: The study aimed to assess the frequency, indications, and outcome of additional ocular procedures after initial treatment of vitrectomy (VIT) or tap-biopsy (TAP) for patients with endophthalmitis after cataract extraction. DESIGN: The study design was an analysis of observational data collected as part of a multicenter, randomized clinical trial. PARTICIPANTS: Of the 420 patients enrolled in the Endophthalmitis Vitrectomy Study, the 148 who had additional procedures were compared with the 272 who did not. MAIN OUTCOME MEASURES: The types, indications, and number of additional ocular procedures were assessed. A masked examiner measured visual acuity 9 to 12 months after study entry. RESULTS: Within 1 week of study entry, 8% of VIT eyes and 13% of TAP eyes underwent additional procedures, 14% for complications of the initial procedure and 86% for worsening ocular inflammation or infection. Cultures were obtained in 33 of the 38 eyes operated on for worsening inflammation or infection and were positive in 42%. Cultures obtained from the early additional procedures were positive more frequently in eyes with an initial TAP (71%) than in eyes with an initial VIT (13%). Both virulence of initial microbiologic organism isolated and poor presenting vision were risk factors for requirement of reoperation. In all cases in which a single organism was cultured at the initial procedure, when the reculture was positive, it was the same organism. Late additional procedures (after 7 days) were required in 27% of patients. Visual outcome was much worse for eyes that had an additional procedure compared to eyes that did not, and this was especially the case for eyes that had an early additional procedure. Only 15% of eyes that had an early additional procedure achieved 20/40 visual acuity as compared to 57% of eyes that did not. CONCLUSION: Need for an additional procedure was a marker of more severe disease, and patients who underwent additional procedures achieved poorer visual acuity at final follow-up.

Bacteria↗

PubMed1991

Efficacy of multiple balloon aortic valvuloplasty procedures. The Mansfield Scientific Aortic Valvuloplasty Registry Investigators.

To determine the efficacy of a second balloon aortic valvuloplasty procedure in comparison with the original procedure, 47 patients (18 men, 29 women; mean age 77 +/- 10 years) who underwent two balloon aortic valvuloplasty procedures over a mean interval of 6.4 months between procedures (range 2 days to 15 months) were retrospectively examined. The mean pressure gradient across the aortic valve was significantly higher before the first than before the second valvuloplasty procedure (62 +/- 21 vs. 53 +/- 21 mm Hg; p less than 0.05) and after the first compared with after the second procedure (32 +/- 13 vs. 28 +/- 14 mm Hg; p less than 0.05). The cardiac output and stroke volume after the first procedure were significantly greater than the values for these variables after the second procedure (4.4 +/- 1.1 vs. 3.8 +/- 1.1 liters/min; p less than 0.05; and 54 +/- 17 vs. 47 +/- 15 ml/beat; p less than 0.05, respectively). There were no significant differences in the change observed in any variable between the first and second procedures. At a mean follow-up interval of 5.3 months (range 6 days to 15 months) after the second procedure 18 (38%) of the 47 patients had died, 12 (25%) required surgical valve replacement and 4 (8%) required a third valvuloplasty procedure. Overall, 31 (66%) of 47 patients met clinical failure end points after the second procedure. Three patients had two failure end points. The 47 patients were divided into two groups on the basis of the interval between valvuloplasty procedures.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2003

Pain management in nursing procedures on premature babies.

BACKGROUND: Pain can be caused to premature babies when nursing and other procedures are carried out. Procedural pain management for these babies raises challenging questions for health care professionals. Optimal pain management for premature babies can be reached by using and further developing existing pharmacological and non-pharmacological pain alleviation methods for procedural pain before, during, and after procedures. AIMS: The aims of this study were to describe the environment of pain management in nursing procedures and examinations with premature babies; to describe preparation of the baby for the procedure; to describe non-pharmacological pain alleviation methods during and after the procedures; and to develop a process describing procedural pain management in premature babies. METHOD: The material for this study consisted of journal articles on non-pharmacological procedural pain alleviation in infants published between 1994 and 2002. During this period knowledge of pain management in premature babies has improved considerably. The study was based on the method of content analysis. FINDINGS: Procedural pain management in premature babies was described by researchers as a process comprising: (1) an environment that is favourable to effective pain management, (2) safe preparation of the baby for the procedure, (3) pain alleviation during the procedure, and (4) restoring the baby's sense of security after the procedure. Pain management is recommended to be used alone or together with pharmacological interventions. Additionally, systematic pain management requires documentation of the whole pain management process. CONCLUSION: Pain management can be described as a process. It is important to test and assess this process and individual non-pharmacological pain management methods in practical nursing situations. The findings of this review can be used to improve pain management methods in premature babies.

Anesthetics, Local↗

PubMed2000

Confidence of graduating internal medicine residents to perform ambulatory procedures.

OBJECTIVE: To evaluate the training of graduating internal medicine residents to perform 13 common ambulatory procedures, 3 inpatient procedures, and 3 screening examinations. DESIGN: Self-administered descriptive survey. SETTING: Internal medicine training programs associated with 9 medical schools in the eastern United States. PARTICIPANTS: Graduating residents (N = 128); response rate, 60%. MEASUREMENTS AND MAIN RESULTS: The total number of procedures performed during residency, importance for primary care physicians to perform these procedures, confidence to perform these procedures, and helpfulness of rotations for learning procedures were assessed. The majority of residents performed only 2 of 13 outpatient procedures 10 or more times during residency: simple spirometry and minor wound suturing. For all other procedures, the median number performed was 5 or fewer. The percentage of residents attributing high importance to a procedure was significantly greater than the percentage reporting high confidence for 8 of 13 ambulatory procedures; for all inpatient procedures, residents reported significantly higher confidence than importance. Continuity clinic and block ambulatory rotations were not considered helpful for learning ambulatory procedures. CONCLUSIONS: Though residents in this sample considered most ambulatory procedures important for primary care physicians, they performed them infrequently, if at all, during residency and did not consider their continuity clinic experience helpful for learning these skills. Training programs need to address this deficiency by modifying the curriculum to ensure that these skills are taught to residents who anticipate a career in primary care medicine.

Adult↗

PubMed2005

The fallback procedure for evaluating a single family of hypotheses.

In testing multiple hypotheses, control of the familywise error rate is often considered. We develop a procedure called the "fallback procedure" to control the familywise error rate when multiple primary hypotheses are tested. With the fallback procedure, the Type I error rate (alpha) is partitioned among the various hypotheses of interest. Unlike the standard Bonferroni adjustment, however, testing hypotheses proceeds in an order determined a priori. As long as hypotheses are rejected, the Type I error rate can be accumulated, making tests of later hypotheses more powerful than under the Bonferroni procedure. Unlike the fixed sequence test, the fallback test allows consideration of all hypotheses even if one or more hypotheses are not rejected early in the process, thereby avoiding a common concern about the fixed sequence procedure. We develop properties of the fallback procedure, including control of the familywise error rate for an arbitrary number of hypotheses via illustrating the procedure as a closed testing procedure, as well as making the test more powerful via alpha exhaustion. We compare it to other procedures for controlling familywise error rates, finding that the fallback procedure is a viable alternative to the fixed sequence procedure when there is some doubt about the power for the first hypothesis. These results expand on the previously developed properties of the fallback procedure (Wiens, 2003). Several examples are discussed to illustrate the relative advantages of the fallback procedure.

Data Interpretation, Statistical↗