Joseph K. Asbury, MD

Internal medicine residency programs, the major pipeline for incoming hospitalists, often provide little hands‐on experience in bedside procedures. Some residents may only insert 1 central venous catheter every 4 months on the general medicine wards,1 and others may gain little more experience during intensive care unit rotations. As seen in the survey presented by Grover et al.2 in this issue of the Journal, after 3 years of training in all types of patient care units, residents often count their accumulated experience on their fingers and toes. Such sparse experience hardly leads to expertise. Recognizing this pervasive lack of training the American Board of Internal Medicine narrowed its certification requirements for bedside procedures in 2006.3 Residents are no longer expected to perform bedside procedures but instead to know them. This important revision acknowledges that manual skills training should neither be assumed nor expendablecontinuing to do so is too risky.4 Yet as internal medicine residency programs focus their bedside procedure training on cognitive competence, the ongoing exodus of bedside procedures to the up‐market hands of subspecialists, surgeons, anesthesiologists, and interventional radiologists5 will likely accelerate.

But why should hospitalists disrupt this trend? Bedside procedures are common and not always conveniently needed during daytime hours. Roughly one‐tenth of general medicine inpatients receive a central venous catheter (CVC) insertion, a lumbar puncture, an abdominal paracentesis, or a thoracentesis.6 Among these patients, about one‐half will urgently need procedures during off‐hours. Outside of the emergency department, hospitalists will likely remain the only group of physicians available at the bedsides of general medicine inpatients 7 days a week, 24 hours per day. Thus, in developing our particular practice system to best serve our patients,7 we believe that hospitalists ought to remain principals in ensuring that inpatients have ready access to expertly performed bedside procedures.

Yet unfortunately, given the limited training in manual skills that today's internal medicine residents receive, hospitalists are increasingly less prepared to provide this access themselves.8 State‐of‐the‐art training methods developed by medical specialties that depend largely on manual skills provide promising potential solutions for both future and practicing hospitalists.9 In particular, patient simulators can provide trainees with the essential hands‐on experience they often lack. In contrast to the ad hoc see‐one, do‐one, teach‐one method in current widespread use, training with simulators has distinct advantages. First, simulators obviate the increasingly awkward consent as patients grow savvier about safety concerns and (understandably) less tolerant of a novice's need to acquire experience.10 Second, training with simulators is controlled so that anatomic variations, comorbidities, patient discomfort, and time pressuresthough important real‐world factorscan be artificially removed in the earlier cognitive and integrative stages of training.11 Third, immediate feedback, which at the bedside of real patients is often empathetically avoided or delivered in cryptic hand signals, can be unmistakably unmuted and honest in the simulator setting. Fourth, and most important to the development of expertise, simulators can be used repeatedly, allowing trainees first to become facile in the mechanics of their performance (eg, holding an ultrasound probe for real‐time guidance or knowing how it feels to enter a vein) before attempting a procedure on a patient.

Three examples of patient simulators used to train internal medicine residents in CVC insertion are presented in this issue of the Journal.1214 Using observers who adhered to objective, a priori assessment criteria, both Rosen et al.13 and Millington et al.14 carefully demonstrate that internal medicine residents' manual skills can improve with patient simulators. Given the understood importance of hands‐on experience in manual skills training,15 these anticipated findings are important validations of simulator theory. The work by Barsuk et al.12 goes further to begin to examine whether or not simulator training actually leads to improved patient outcomesthe holy grail of such research. In this observational study, compared to residents who did not undergo simulator training, those who did undergo such training had 1 fewer needle passes during successful CVC insertions. Given the relative infrequency of periprocedural complications, this study was understandably underpowered to measure true complications, relying instead on the often‐used surrogate of needle passes. Nonetheless, this work will serve as an important initial example of why simulator training may be worth the effort.

To direct participation in simulator training, we endorse selecting trainees who will perform bedside procedures in their future practice.16 Given the trend in manual skills training among internal medicine residency training programs, hospitalist programs may need to shoulder this effort themselves. Thankfully, simulator training need not be expensive. Based on transfer‐of‐learning research,17 the fidelity of the simulator is less important than the accumulated experience it can afford. Even low‐fidelity simulators, such as the store‐bought whole chicken used by Rosen et al.,13 may preserve trainees' manual skills just as effectively as the expensive, bionic, high‐fidelity simulators used by Barsuk et al.12 and Millington et al.14

Beyond the costs of training, however, hospital administrators and hospitalist group leaders have more complex externalities and opportunity costs to weigh when evaluating which physician groups should perform bedside procedures. The intuitively lower‐cost strategy for hospitals, we believe, would be to ask hospitalists to perform bedside procedures at patients' bedsides instead of asking, say, highly‐paid interventional radiologists to perform the same procedures in fully‐staffed fluoroscopy suites. There is, however, very little research to help inform these decisions. As hospitalists, we know firsthand that modern healthcare remuneration is based more on doing than on knowing. Yet, whether or not bedside procedures afford financial incentives for hospitalists is unclearmuch will depend on local factors. Regardless of the finances, we believe that hospitalists skilled in performing common bedside procedures can improve the quality and efficiency of care delivery at patients' bedsides. So, instead of a call to arms for yet another turf battle, let's continue development of state‐of‐the‐art training methods like simulators to ensure that future hospitalists can expertly perform bedside procedures. After all, fighting for improvements in patient safety is a battle that we hospitalists know how to win.

Internal medicine residency programs, the major pipeline for incoming hospitalists, often provide little hands‐on experience in bedside procedures. Some residents may only insert 1 central venous catheter every 4 months on the general medicine wards,1 and others may gain little more experience during intensive care unit rotations. As seen in the survey presented by Grover et al.2 in this issue of the Journal, after 3 years of training in all types of patient care units, residents often count their accumulated experience on their fingers and toes. Such sparse experience hardly leads to expertise. Recognizing this pervasive lack of training the American Board of Internal Medicine narrowed its certification requirements for bedside procedures in 2006.3 Residents are no longer expected to perform bedside procedures but instead to know them. This important revision acknowledges that manual skills training should neither be assumed nor expendablecontinuing to do so is too risky.4 Yet as internal medicine residency programs focus their bedside procedure training on cognitive competence, the ongoing exodus of bedside procedures to the up‐market hands of subspecialists, surgeons, anesthesiologists, and interventional radiologists5 will likely accelerate.

But why should hospitalists disrupt this trend? Bedside procedures are common and not always conveniently needed during daytime hours. Roughly one‐tenth of general medicine inpatients receive a central venous catheter (CVC) insertion, a lumbar puncture, an abdominal paracentesis, or a thoracentesis.6 Among these patients, about one‐half will urgently need procedures during off‐hours. Outside of the emergency department, hospitalists will likely remain the only group of physicians available at the bedsides of general medicine inpatients 7 days a week, 24 hours per day. Thus, in developing our particular practice system to best serve our patients,7 we believe that hospitalists ought to remain principals in ensuring that inpatients have ready access to expertly performed bedside procedures.

Yet unfortunately, given the limited training in manual skills that today's internal medicine residents receive, hospitalists are increasingly less prepared to provide this access themselves.8 State‐of‐the‐art training methods developed by medical specialties that depend largely on manual skills provide promising potential solutions for both future and practicing hospitalists.9 In particular, patient simulators can provide trainees with the essential hands‐on experience they often lack. In contrast to the ad hoc see‐one, do‐one, teach‐one method in current widespread use, training with simulators has distinct advantages. First, simulators obviate the increasingly awkward consent as patients grow savvier about safety concerns and (understandably) less tolerant of a novice's need to acquire experience.10 Second, training with simulators is controlled so that anatomic variations, comorbidities, patient discomfort, and time pressuresthough important real‐world factorscan be artificially removed in the earlier cognitive and integrative stages of training.11 Third, immediate feedback, which at the bedside of real patients is often empathetically avoided or delivered in cryptic hand signals, can be unmistakably unmuted and honest in the simulator setting. Fourth, and most important to the development of expertise, simulators can be used repeatedly, allowing trainees first to become facile in the mechanics of their performance (eg, holding an ultrasound probe for real‐time guidance or knowing how it feels to enter a vein) before attempting a procedure on a patient.

Three examples of patient simulators used to train internal medicine residents in CVC insertion are presented in this issue of the Journal.1214 Using observers who adhered to objective, a priori assessment criteria, both Rosen et al.13 and Millington et al.14 carefully demonstrate that internal medicine residents' manual skills can improve with patient simulators. Given the understood importance of hands‐on experience in manual skills training,15 these anticipated findings are important validations of simulator theory. The work by Barsuk et al.12 goes further to begin to examine whether or not simulator training actually leads to improved patient outcomesthe holy grail of such research. In this observational study, compared to residents who did not undergo simulator training, those who did undergo such training had 1 fewer needle passes during successful CVC insertions. Given the relative infrequency of periprocedural complications, this study was understandably underpowered to measure true complications, relying instead on the often‐used surrogate of needle passes. Nonetheless, this work will serve as an important initial example of why simulator training may be worth the effort.

To direct participation in simulator training, we endorse selecting trainees who will perform bedside procedures in their future practice.16 Given the trend in manual skills training among internal medicine residency training programs, hospitalist programs may need to shoulder this effort themselves. Thankfully, simulator training need not be expensive. Based on transfer‐of‐learning research,17 the fidelity of the simulator is less important than the accumulated experience it can afford. Even low‐fidelity simulators, such as the store‐bought whole chicken used by Rosen et al.,13 may preserve trainees' manual skills just as effectively as the expensive, bionic, high‐fidelity simulators used by Barsuk et al.12 and Millington et al.14

Beyond the costs of training, however, hospital administrators and hospitalist group leaders have more complex externalities and opportunity costs to weigh when evaluating which physician groups should perform bedside procedures. The intuitively lower‐cost strategy for hospitals, we believe, would be to ask hospitalists to perform bedside procedures at patients' bedsides instead of asking, say, highly‐paid interventional radiologists to perform the same procedures in fully‐staffed fluoroscopy suites. There is, however, very little research to help inform these decisions. As hospitalists, we know firsthand that modern healthcare remuneration is based more on doing than on knowing. Yet, whether or not bedside procedures afford financial incentives for hospitalists is unclearmuch will depend on local factors. Regardless of the finances, we believe that hospitalists skilled in performing common bedside procedures can improve the quality and efficiency of care delivery at patients' bedsides. So, instead of a call to arms for yet another turf battle, let's continue development of state‐of‐the‐art training methods like simulators to ensure that future hospitalists can expertly perform bedside procedures. After all, fighting for improvements in patient safety is a battle that we hospitalists know how to win.

Internal medicine residency programs, the major pipeline for incoming hospitalists, often provide little hands‐on experience in bedside procedures. Some residents may only insert 1 central venous catheter every 4 months on the general medicine wards,1 and others may gain little more experience during intensive care unit rotations. As seen in the survey presented by Grover et al.2 in this issue of the Journal, after 3 years of training in all types of patient care units, residents often count their accumulated experience on their fingers and toes. Such sparse experience hardly leads to expertise. Recognizing this pervasive lack of training the American Board of Internal Medicine narrowed its certification requirements for bedside procedures in 2006.3 Residents are no longer expected to perform bedside procedures but instead to know them. This important revision acknowledges that manual skills training should neither be assumed nor expendablecontinuing to do so is too risky.4 Yet as internal medicine residency programs focus their bedside procedure training on cognitive competence, the ongoing exodus of bedside procedures to the up‐market hands of subspecialists, surgeons, anesthesiologists, and interventional radiologists5 will likely accelerate.

But why should hospitalists disrupt this trend? Bedside procedures are common and not always conveniently needed during daytime hours. Roughly one‐tenth of general medicine inpatients receive a central venous catheter (CVC) insertion, a lumbar puncture, an abdominal paracentesis, or a thoracentesis.6 Among these patients, about one‐half will urgently need procedures during off‐hours. Outside of the emergency department, hospitalists will likely remain the only group of physicians available at the bedsides of general medicine inpatients 7 days a week, 24 hours per day. Thus, in developing our particular practice system to best serve our patients,7 we believe that hospitalists ought to remain principals in ensuring that inpatients have ready access to expertly performed bedside procedures.

Yet unfortunately, given the limited training in manual skills that today's internal medicine residents receive, hospitalists are increasingly less prepared to provide this access themselves.8 State‐of‐the‐art training methods developed by medical specialties that depend largely on manual skills provide promising potential solutions for both future and practicing hospitalists.9 In particular, patient simulators can provide trainees with the essential hands‐on experience they often lack. In contrast to the ad hoc see‐one, do‐one, teach‐one method in current widespread use, training with simulators has distinct advantages. First, simulators obviate the increasingly awkward consent as patients grow savvier about safety concerns and (understandably) less tolerant of a novice's need to acquire experience.10 Second, training with simulators is controlled so that anatomic variations, comorbidities, patient discomfort, and time pressuresthough important real‐world factorscan be artificially removed in the earlier cognitive and integrative stages of training.11 Third, immediate feedback, which at the bedside of real patients is often empathetically avoided or delivered in cryptic hand signals, can be unmistakably unmuted and honest in the simulator setting. Fourth, and most important to the development of expertise, simulators can be used repeatedly, allowing trainees first to become facile in the mechanics of their performance (eg, holding an ultrasound probe for real‐time guidance or knowing how it feels to enter a vein) before attempting a procedure on a patient.

Three examples of patient simulators used to train internal medicine residents in CVC insertion are presented in this issue of the Journal.1214 Using observers who adhered to objective, a priori assessment criteria, both Rosen et al.13 and Millington et al.14 carefully demonstrate that internal medicine residents' manual skills can improve with patient simulators. Given the understood importance of hands‐on experience in manual skills training,15 these anticipated findings are important validations of simulator theory. The work by Barsuk et al.12 goes further to begin to examine whether or not simulator training actually leads to improved patient outcomesthe holy grail of such research. In this observational study, compared to residents who did not undergo simulator training, those who did undergo such training had 1 fewer needle passes during successful CVC insertions. Given the relative infrequency of periprocedural complications, this study was understandably underpowered to measure true complications, relying instead on the often‐used surrogate of needle passes. Nonetheless, this work will serve as an important initial example of why simulator training may be worth the effort.

To direct participation in simulator training, we endorse selecting trainees who will perform bedside procedures in their future practice.16 Given the trend in manual skills training among internal medicine residency training programs, hospitalist programs may need to shoulder this effort themselves. Thankfully, simulator training need not be expensive. Based on transfer‐of‐learning research,17 the fidelity of the simulator is less important than the accumulated experience it can afford. Even low‐fidelity simulators, such as the store‐bought whole chicken used by Rosen et al.,13 may preserve trainees' manual skills just as effectively as the expensive, bionic, high‐fidelity simulators used by Barsuk et al.12 and Millington et al.14

Beyond the costs of training, however, hospital administrators and hospitalist group leaders have more complex externalities and opportunity costs to weigh when evaluating which physician groups should perform bedside procedures. The intuitively lower‐cost strategy for hospitals, we believe, would be to ask hospitalists to perform bedside procedures at patients' bedsides instead of asking, say, highly‐paid interventional radiologists to perform the same procedures in fully‐staffed fluoroscopy suites. There is, however, very little research to help inform these decisions. As hospitalists, we know firsthand that modern healthcare remuneration is based more on doing than on knowing. Yet, whether or not bedside procedures afford financial incentives for hospitalists is unclearmuch will depend on local factors. Regardless of the finances, we believe that hospitalists skilled in performing common bedside procedures can improve the quality and efficiency of care delivery at patients' bedsides. So, instead of a call to arms for yet another turf battle, let's continue development of state‐of‐the‐art training methods like simulators to ensure that future hospitalists can expertly perform bedside procedures. After all, fighting for improvements in patient safety is a battle that we hospitalists know how to win.

Hand‐carried ultrasound echocardiography (HCUE) can help noncardiologists answer well‐defined questions at patients' bedsides in less than 10 minutes.1, 2 Indeed, intensivists3 and emergency department physicians4 already use HCUE to make rapid, point‐of‐care assessments. Since cardiovascular diagnoses are common among general medicine inpatients, HCUE may become an important skill for hospitalists to learn.5

However, uncertainty exists about the duration of HCUE training for hospitalists. In 2002, experts from the American Society of Echocardiography (ASE) published recommendations on training requirements for HCUE.6 With limited data on the safety or performance of HCUE training programs, which had just begun to emerge, the ASE borrowed from the proven training recommendations for standard echocardiography (SE). They recommended that all HCUE trainees, cardiologist and noncardiologist alike, complete level 1 SE training: 75 personally‐performed and 150 personally‐interpreted echocardiographic examinations. Since then, however, several HCUE training programs designed for noncardiologists have emerged.2, 5, 710 These alternative programs suggest that the ASE's recommended duration of training may be too long, particularly for focused HCUE that is limited to a few relatively simple assessments. It is important not to overshoot the requirements of HCUE training, because doing so may discourage groups of noncardiologists, like hospitalists, who may derive great benefits from HCUE.11

To address this uncertainty for hospitalists, we first developed a brief HCUE training program to assess 6 important cardiac abnormalities. We then studied the diagnostic accuracy of HCUE by hospitalists as a test of these 6 cardiac abnormalities assessed by SE.

Patients and Methods

Setting and Subjects

This prospective cohort study was performed at Stroger Hospital of Cook County, a 500‐bed public teaching hospital in Chicago, IL, from March through May of 2007. The cohort was adult inpatients who were referred for SE on weekdays from 3 distinct patient care units (Figure 1). We used 2 sampling modes to balance practical constraints (short‐stay unit [SSU] patients were more localized and, therefore, easier to study) with clinical diversity. We consecutively sampled patients from our SSU, where adults with provisional cardiovascular diagnoses are admitted if they might be eligible for discharge with in 3 days.12 But we used random number tables with a daily unique starting point to randomly sample patients from the general medical wards and the coronary care unit (CCU). Patients were excluded if repositioning them for HCUE was potentially harmful. The study was approved by our hospital's institutional review board, and we obtained written informed consent from all enrolled patients.

Figure 1

Results

During the 3 month study period, 654 patients were referred for SE from the 3 participating patient care units (Figure 1). Among these, 65 patients were ineligible because their SE was performed on the weekend and 178 other patients were not randomized from the general medical wards and CCU. From the remaining eligible patients, 322 underwent HCUE and 314 (98% of 322) underwent both SE and HCUE. Individual SE assessments were not interpretable (and therefore excluded) due to poor image quality for LA enlargement in 1 patient and IVC dilatation in 30 patients. Eighty‐three percent of patients who underwent SE (260/314) were referred to assess LV function (Table 3). The prevalence of the 6 clinically pertinent cardiac abnormalities under study ranged from 1% for moderate or large pericardial effusion to 25% for LV systolic dysfunction. Overall, 40% of patients had at least 1 out of 6 cardiac abnormalities.

Each hospitalist performed a similar total number of HCUE examinations (range, 3447). The median time difference between performance of SE and HCUE was 2.8 hours (25th75th percentiles, 1.45.1). Despite the high prevalence of chronic obstructive pulmonary disease and obesity, hospitalists considered HCUE assessments indeterminate in only 2% to 6% of the 6 assessments made for each patient (Table 4). Among the 38 patients (12% of 322) with any indeterminate HCUE assessment, 24 patients had only 1 out of 6 possible. Hospitalists completed HCUE in a median time of 28 minutes (25th‐75th percentiles, 2035), which included the time to record 7 best‐quality moving images and to fill out the research data collection form.

When HCUE results were analyzed as dichotomous values, positive likelihood ratios ranged from 2.5 to 21, and negative likelihood ratios ranged from 0 to 0.4 (Table 5). Positive and negative likelihood ratios were both sufficiency high and low to respectively increase and decrease by 5‐fold the prior odds of 3 out of 6 cardiac abnormalities: LV systolic dysfunction, moderate or severe MR regurgitation, and moderate or large pericardial effusion. Considering HCUE results as ordinal values for ROC analysis yielded additional diagnostic information (Figure 2). For example, the likelihood ratio of 1.0 (95% CI, 0.42.0) for borderline positive moderate or severe LA enlargement increased to 29 (range, 1362) for extreme positive results. Areas under the ROC curves were 0.9 for 4 out of 6 cardiac abnormalities.

Figure 2

LV systolic dysfunction and IVC dilatation were both prevalent enough to meet our criterion to examine interobserver variability; the mean number of abnormal patients per hospitalist was 10 patients for LV systolic dysfunction and 6 patients for IVC dilatation. For LV systolic dysfunction, SDs around mean sensitivity (84%) and specificity (87%) were 12% and 6%, respectively. For IVC dilatation, SDs around mean sensitivity (58%) and specificity (86%) were 24% and 7%, respectively.

Discussion

We found that, after a 27‐hour training program, hospitalists performed HCUE with moderate to excellent diagnostic accuracy for 6 important cardiac abnormalities. For example, hospitalists' assessments of LV systolic function yielded positive and negative likelihood ratios of 6.9 (95% CI, 4.99.8) and 0.2 (95% CI, 0.10.3), respectively. At the bedsides of patients with acute heart failure, therefore, hospitalists could use HCUE to lower or raise the 50:50 chance of LV systolic dysfunction30 to 15% or 85%, respectively. Whether or not these posttest likelihoods are extreme enough to cross important thresholds will depend on the clinical context. Yet these findings demonstrate how HCUE has the potential to provide hospitalists with valuable point‐of‐care data that are otherwise unavailableeither because routine clinical assessments are unreliable31 or because echocardiographic services are not immediately accessible.1

In fact, recent data from the Joint Commission on Accreditation of Healthcare Organizations shows how inaccessible SE may be. Approximately one‐quarter of hospitals in the United States send home about 10% of patients with acute heart failure without echocardiographic assessment of LV systolic function before, during, or immediately after hospitalization.32 In doing so, these hospitals leave unmet the 2002 National Quality Improvement Goal of universal assessment of LV systolic function for all heart failure patients. Hospitalists could close this quality gap with routine, 10‐minute HCUE assessments in all patients admitted with acute heart failure. (Our research HCUE protocol required a median time of 28 minutes, but this included time to assess 5 other cardiac abnormalities and collect data for research purposes). Until the clinical consequences of introducing hospitalist‐performed HCUE are studied, potential benefits like this are tentative. But our findings suggest that training hospitalists to accurately perform HCUE can be successfully accomplished in just 27 hours.

Other studies of HCUE training programs for noncardiologists have also challenged the opinion that learning to perform HCUE requires more than 100 hours of training.2, 711 Yet only 1 prior study has examined an HCUE training program for hospitalists.5 In this study by Martin et al.,5 hospitalists completed 5 supervised HCUE examinations and 6 hours of interpretation training before investigators scored their image acquisition and interpretation skills from 30 unsupervised HCUE examinations. To estimate their final skill levels at the completion of all 35 examinations by accounting for an initially steep learning curve, investigators then adjusted these scores with regression models. Despite these upward adjustments, hospitalists' image acquisition and interpretation scores were low in comparison to echocardiographic technicians and cardiology fellows. Besides these adjusted measurements of hospitalists' skills, however, Martin et al.5 unfortunately did not also report standard measures of diagnostic accuracy, like those proposed by the Standards for Reporting of Diagnostic Accuracy (STARD) initiative.33 Therefore, direct comparisons to the present study are difficult. Nevertheless, their findings suggest that a training program limited to 5 supervised HCUE examinations may be inadequate for hospitalists. In fact, the same group's earlier study of medical trainees suggested a minimum of 30 supervised HCUE examinations.9 We chose to design our hospitalist training program based on this minimum, though they surprisingly did not.5 As others continue to refine the components of hospitalist HCUE training programs, such as the optimal number of supervised examinations, our program could serve as a reasonable comparative example: more rigorous than the program designed by Martin et al.5 but more feasible than ASE level 1 training.

The number and complexity of assessments taught in HCUE training programs will determine their duration. With ongoing advancements in HCUE technology, there is a growing list of potential assessments to choose from. Although HCUE training programs ought to include assessments with proven clinical applications, there are no trials of HCUE‐directed care to inform such decisions. In their absence, therefore, we chose 6 assessments based on the following 3 criteria. First, our assessments were otherwise not reliably available from routine clinical data, such as the physical examination. Second, our assessments were straightforward: easy to learn and simple to perform. Here, we based our reasoning on an expectation that the value of HCUE lies not in highly complex, state‐of‐the‐art assessmentswhich are best left to echocardiographers equipped with SEbut in simple, routine assessments made with highly portable machines that grant noncardiologists newfound access to point‐of‐care data.34 Third, our assessments were clinically pertinent and, where appropriate, defined by cut‐points at levels of severity that often lead to changes in management. We suspect that setting high cut‐points has the salutary effects of making assessments easier to learn and more accurate, because distinguishing mild abnormalities is likely the most challenging aspect of echocardiographic interpretation.35 Whether or not our choices of assessments, and their cut‐points, are optimal has yet to be determined by future research designed to study how they affect patient outcomes. Given our hospitalists' performance in the present study, these assessments seem worthy of such future research.

Our study had several limitations. We studied physicians and patients from only 1 hospital; similar studies performed in different settings, particularly among patients with different proportions and manifestations of disease, may find different results. Nevertheless, our sampling method of prospectively enrolling consecutive patients strengthens our findings. Some echocardiographic measurement methods used by our hospitalists differed in subtle ways from echocardiography guideline recommendations.35 We chose our methods (Table 2) for 2 reasons. First, whenever possible, we chose methods of interpretation that coincided with our local cardiologists'. Second, we chose simplicity over precision. For example, the biplane method of disks, or modified Simpson's rule, is the preferred volumetric method of calculating LA size.35 This method requires tracing the contours of the LA in 2 planes and then dividing the LA volume into stacked oval disks for calculation. We chose instead to train our hospitalists in a simpler method based on 2 linear measurements. Any loss of precision, however, was balanced by a large gain in simplicity. Regardless, minor variations in LA size are not likely to affect hospitalists' bedside evaluations. Finally, we did not validate the results of our reference standard (SE) by documenting interobserver reliability. Yet, because SE is generally accurate for the 6 cardiac abnormalities under study, the effect of this bias should be small.

These limitations can be addressed best by controlled trials of HCUE‐directed care. These trials will determine the clinical impact of hospitalist‐performed HCUE and, in turn, inform our design of HCUE training programs. As the current study shows, training hospitalists to participate in such trials is feasible: like other groups of noncardiologists, hospitalists can accurately perform HCUE after a brief training program. Whether or not hospitalists should perform HCUE requires further study.

Hand‐carried ultrasound echocardiography (HCUE) can help noncardiologists answer well‐defined questions at patients' bedsides in less than 10 minutes.1, 2 Indeed, intensivists3 and emergency department physicians4 already use HCUE to make rapid, point‐of‐care assessments. Since cardiovascular diagnoses are common among general medicine inpatients, HCUE may become an important skill for hospitalists to learn.5

However, uncertainty exists about the duration of HCUE training for hospitalists. In 2002, experts from the American Society of Echocardiography (ASE) published recommendations on training requirements for HCUE.6 With limited data on the safety or performance of HCUE training programs, which had just begun to emerge, the ASE borrowed from the proven training recommendations for standard echocardiography (SE). They recommended that all HCUE trainees, cardiologist and noncardiologist alike, complete level 1 SE training: 75 personally‐performed and 150 personally‐interpreted echocardiographic examinations. Since then, however, several HCUE training programs designed for noncardiologists have emerged.2, 5, 710 These alternative programs suggest that the ASE's recommended duration of training may be too long, particularly for focused HCUE that is limited to a few relatively simple assessments. It is important not to overshoot the requirements of HCUE training, because doing so may discourage groups of noncardiologists, like hospitalists, who may derive great benefits from HCUE.11

To address this uncertainty for hospitalists, we first developed a brief HCUE training program to assess 6 important cardiac abnormalities. We then studied the diagnostic accuracy of HCUE by hospitalists as a test of these 6 cardiac abnormalities assessed by SE.

Patients and Methods

Setting and Subjects

This prospective cohort study was performed at Stroger Hospital of Cook County, a 500‐bed public teaching hospital in Chicago, IL, from March through May of 2007. The cohort was adult inpatients who were referred for SE on weekdays from 3 distinct patient care units (Figure 1). We used 2 sampling modes to balance practical constraints (short‐stay unit [SSU] patients were more localized and, therefore, easier to study) with clinical diversity. We consecutively sampled patients from our SSU, where adults with provisional cardiovascular diagnoses are admitted if they might be eligible for discharge with in 3 days.12 But we used random number tables with a daily unique starting point to randomly sample patients from the general medical wards and the coronary care unit (CCU). Patients were excluded if repositioning them for HCUE was potentially harmful. The study was approved by our hospital's institutional review board, and we obtained written informed consent from all enrolled patients.

Figure 1

Results

During the 3 month study period, 654 patients were referred for SE from the 3 participating patient care units (Figure 1). Among these, 65 patients were ineligible because their SE was performed on the weekend and 178 other patients were not randomized from the general medical wards and CCU. From the remaining eligible patients, 322 underwent HCUE and 314 (98% of 322) underwent both SE and HCUE. Individual SE assessments were not interpretable (and therefore excluded) due to poor image quality for LA enlargement in 1 patient and IVC dilatation in 30 patients. Eighty‐three percent of patients who underwent SE (260/314) were referred to assess LV function (Table 3). The prevalence of the 6 clinically pertinent cardiac abnormalities under study ranged from 1% for moderate or large pericardial effusion to 25% for LV systolic dysfunction. Overall, 40% of patients had at least 1 out of 6 cardiac abnormalities.

Each hospitalist performed a similar total number of HCUE examinations (range, 3447). The median time difference between performance of SE and HCUE was 2.8 hours (25th75th percentiles, 1.45.1). Despite the high prevalence of chronic obstructive pulmonary disease and obesity, hospitalists considered HCUE assessments indeterminate in only 2% to 6% of the 6 assessments made for each patient (Table 4). Among the 38 patients (12% of 322) with any indeterminate HCUE assessment, 24 patients had only 1 out of 6 possible. Hospitalists completed HCUE in a median time of 28 minutes (25th‐75th percentiles, 2035), which included the time to record 7 best‐quality moving images and to fill out the research data collection form.

When HCUE results were analyzed as dichotomous values, positive likelihood ratios ranged from 2.5 to 21, and negative likelihood ratios ranged from 0 to 0.4 (Table 5). Positive and negative likelihood ratios were both sufficiency high and low to respectively increase and decrease by 5‐fold the prior odds of 3 out of 6 cardiac abnormalities: LV systolic dysfunction, moderate or severe MR regurgitation, and moderate or large pericardial effusion. Considering HCUE results as ordinal values for ROC analysis yielded additional diagnostic information (Figure 2). For example, the likelihood ratio of 1.0 (95% CI, 0.42.0) for borderline positive moderate or severe LA enlargement increased to 29 (range, 1362) for extreme positive results. Areas under the ROC curves were 0.9 for 4 out of 6 cardiac abnormalities.

Figure 2

LV systolic dysfunction and IVC dilatation were both prevalent enough to meet our criterion to examine interobserver variability; the mean number of abnormal patients per hospitalist was 10 patients for LV systolic dysfunction and 6 patients for IVC dilatation. For LV systolic dysfunction, SDs around mean sensitivity (84%) and specificity (87%) were 12% and 6%, respectively. For IVC dilatation, SDs around mean sensitivity (58%) and specificity (86%) were 24% and 7%, respectively.

Discussion

We found that, after a 27‐hour training program, hospitalists performed HCUE with moderate to excellent diagnostic accuracy for 6 important cardiac abnormalities. For example, hospitalists' assessments of LV systolic function yielded positive and negative likelihood ratios of 6.9 (95% CI, 4.99.8) and 0.2 (95% CI, 0.10.3), respectively. At the bedsides of patients with acute heart failure, therefore, hospitalists could use HCUE to lower or raise the 50:50 chance of LV systolic dysfunction30 to 15% or 85%, respectively. Whether or not these posttest likelihoods are extreme enough to cross important thresholds will depend on the clinical context. Yet these findings demonstrate how HCUE has the potential to provide hospitalists with valuable point‐of‐care data that are otherwise unavailableeither because routine clinical assessments are unreliable31 or because echocardiographic services are not immediately accessible.1

In fact, recent data from the Joint Commission on Accreditation of Healthcare Organizations shows how inaccessible SE may be. Approximately one‐quarter of hospitals in the United States send home about 10% of patients with acute heart failure without echocardiographic assessment of LV systolic function before, during, or immediately after hospitalization.32 In doing so, these hospitals leave unmet the 2002 National Quality Improvement Goal of universal assessment of LV systolic function for all heart failure patients. Hospitalists could close this quality gap with routine, 10‐minute HCUE assessments in all patients admitted with acute heart failure. (Our research HCUE protocol required a median time of 28 minutes, but this included time to assess 5 other cardiac abnormalities and collect data for research purposes). Until the clinical consequences of introducing hospitalist‐performed HCUE are studied, potential benefits like this are tentative. But our findings suggest that training hospitalists to accurately perform HCUE can be successfully accomplished in just 27 hours.

Other studies of HCUE training programs for noncardiologists have also challenged the opinion that learning to perform HCUE requires more than 100 hours of training.2, 711 Yet only 1 prior study has examined an HCUE training program for hospitalists.5 In this study by Martin et al.,5 hospitalists completed 5 supervised HCUE examinations and 6 hours of interpretation training before investigators scored their image acquisition and interpretation skills from 30 unsupervised HCUE examinations. To estimate their final skill levels at the completion of all 35 examinations by accounting for an initially steep learning curve, investigators then adjusted these scores with regression models. Despite these upward adjustments, hospitalists' image acquisition and interpretation scores were low in comparison to echocardiographic technicians and cardiology fellows. Besides these adjusted measurements of hospitalists' skills, however, Martin et al.5 unfortunately did not also report standard measures of diagnostic accuracy, like those proposed by the Standards for Reporting of Diagnostic Accuracy (STARD) initiative.33 Therefore, direct comparisons to the present study are difficult. Nevertheless, their findings suggest that a training program limited to 5 supervised HCUE examinations may be inadequate for hospitalists. In fact, the same group's earlier study of medical trainees suggested a minimum of 30 supervised HCUE examinations.9 We chose to design our hospitalist training program based on this minimum, though they surprisingly did not.5 As others continue to refine the components of hospitalist HCUE training programs, such as the optimal number of supervised examinations, our program could serve as a reasonable comparative example: more rigorous than the program designed by Martin et al.5 but more feasible than ASE level 1 training.

The number and complexity of assessments taught in HCUE training programs will determine their duration. With ongoing advancements in HCUE technology, there is a growing list of potential assessments to choose from. Although HCUE training programs ought to include assessments with proven clinical applications, there are no trials of HCUE‐directed care to inform such decisions. In their absence, therefore, we chose 6 assessments based on the following 3 criteria. First, our assessments were otherwise not reliably available from routine clinical data, such as the physical examination. Second, our assessments were straightforward: easy to learn and simple to perform. Here, we based our reasoning on an expectation that the value of HCUE lies not in highly complex, state‐of‐the‐art assessmentswhich are best left to echocardiographers equipped with SEbut in simple, routine assessments made with highly portable machines that grant noncardiologists newfound access to point‐of‐care data.34 Third, our assessments were clinically pertinent and, where appropriate, defined by cut‐points at levels of severity that often lead to changes in management. We suspect that setting high cut‐points has the salutary effects of making assessments easier to learn and more accurate, because distinguishing mild abnormalities is likely the most challenging aspect of echocardiographic interpretation.35 Whether or not our choices of assessments, and their cut‐points, are optimal has yet to be determined by future research designed to study how they affect patient outcomes. Given our hospitalists' performance in the present study, these assessments seem worthy of such future research.

Our study had several limitations. We studied physicians and patients from only 1 hospital; similar studies performed in different settings, particularly among patients with different proportions and manifestations of disease, may find different results. Nevertheless, our sampling method of prospectively enrolling consecutive patients strengthens our findings. Some echocardiographic measurement methods used by our hospitalists differed in subtle ways from echocardiography guideline recommendations.35 We chose our methods (Table 2) for 2 reasons. First, whenever possible, we chose methods of interpretation that coincided with our local cardiologists'. Second, we chose simplicity over precision. For example, the biplane method of disks, or modified Simpson's rule, is the preferred volumetric method of calculating LA size.35 This method requires tracing the contours of the LA in 2 planes and then dividing the LA volume into stacked oval disks for calculation. We chose instead to train our hospitalists in a simpler method based on 2 linear measurements. Any loss of precision, however, was balanced by a large gain in simplicity. Regardless, minor variations in LA size are not likely to affect hospitalists' bedside evaluations. Finally, we did not validate the results of our reference standard (SE) by documenting interobserver reliability. Yet, because SE is generally accurate for the 6 cardiac abnormalities under study, the effect of this bias should be small.

These limitations can be addressed best by controlled trials of HCUE‐directed care. These trials will determine the clinical impact of hospitalist‐performed HCUE and, in turn, inform our design of HCUE training programs. As the current study shows, training hospitalists to participate in such trials is feasible: like other groups of noncardiologists, hospitalists can accurately perform HCUE after a brief training program. Whether or not hospitalists should perform HCUE requires further study.

Hand‐carried ultrasound echocardiography (HCUE) can help noncardiologists answer well‐defined questions at patients' bedsides in less than 10 minutes.1, 2 Indeed, intensivists3 and emergency department physicians4 already use HCUE to make rapid, point‐of‐care assessments. Since cardiovascular diagnoses are common among general medicine inpatients, HCUE may become an important skill for hospitalists to learn.5

However, uncertainty exists about the duration of HCUE training for hospitalists. In 2002, experts from the American Society of Echocardiography (ASE) published recommendations on training requirements for HCUE.6 With limited data on the safety or performance of HCUE training programs, which had just begun to emerge, the ASE borrowed from the proven training recommendations for standard echocardiography (SE). They recommended that all HCUE trainees, cardiologist and noncardiologist alike, complete level 1 SE training: 75 personally‐performed and 150 personally‐interpreted echocardiographic examinations. Since then, however, several HCUE training programs designed for noncardiologists have emerged.2, 5, 710 These alternative programs suggest that the ASE's recommended duration of training may be too long, particularly for focused HCUE that is limited to a few relatively simple assessments. It is important not to overshoot the requirements of HCUE training, because doing so may discourage groups of noncardiologists, like hospitalists, who may derive great benefits from HCUE.11

To address this uncertainty for hospitalists, we first developed a brief HCUE training program to assess 6 important cardiac abnormalities. We then studied the diagnostic accuracy of HCUE by hospitalists as a test of these 6 cardiac abnormalities assessed by SE.

Patients and Methods

Setting and Subjects

This prospective cohort study was performed at Stroger Hospital of Cook County, a 500‐bed public teaching hospital in Chicago, IL, from March through May of 2007. The cohort was adult inpatients who were referred for SE on weekdays from 3 distinct patient care units (Figure 1). We used 2 sampling modes to balance practical constraints (short‐stay unit [SSU] patients were more localized and, therefore, easier to study) with clinical diversity. We consecutively sampled patients from our SSU, where adults with provisional cardiovascular diagnoses are admitted if they might be eligible for discharge with in 3 days.12 But we used random number tables with a daily unique starting point to randomly sample patients from the general medical wards and the coronary care unit (CCU). Patients were excluded if repositioning them for HCUE was potentially harmful. The study was approved by our hospital's institutional review board, and we obtained written informed consent from all enrolled patients.

Figure 1

Results

During the 3 month study period, 654 patients were referred for SE from the 3 participating patient care units (Figure 1). Among these, 65 patients were ineligible because their SE was performed on the weekend and 178 other patients were not randomized from the general medical wards and CCU. From the remaining eligible patients, 322 underwent HCUE and 314 (98% of 322) underwent both SE and HCUE. Individual SE assessments were not interpretable (and therefore excluded) due to poor image quality for LA enlargement in 1 patient and IVC dilatation in 30 patients. Eighty‐three percent of patients who underwent SE (260/314) were referred to assess LV function (Table 3). The prevalence of the 6 clinically pertinent cardiac abnormalities under study ranged from 1% for moderate or large pericardial effusion to 25% for LV systolic dysfunction. Overall, 40% of patients had at least 1 out of 6 cardiac abnormalities.

Each hospitalist performed a similar total number of HCUE examinations (range, 3447). The median time difference between performance of SE and HCUE was 2.8 hours (25th75th percentiles, 1.45.1). Despite the high prevalence of chronic obstructive pulmonary disease and obesity, hospitalists considered HCUE assessments indeterminate in only 2% to 6% of the 6 assessments made for each patient (Table 4). Among the 38 patients (12% of 322) with any indeterminate HCUE assessment, 24 patients had only 1 out of 6 possible. Hospitalists completed HCUE in a median time of 28 minutes (25th‐75th percentiles, 2035), which included the time to record 7 best‐quality moving images and to fill out the research data collection form.

When HCUE results were analyzed as dichotomous values, positive likelihood ratios ranged from 2.5 to 21, and negative likelihood ratios ranged from 0 to 0.4 (Table 5). Positive and negative likelihood ratios were both sufficiency high and low to respectively increase and decrease by 5‐fold the prior odds of 3 out of 6 cardiac abnormalities: LV systolic dysfunction, moderate or severe MR regurgitation, and moderate or large pericardial effusion. Considering HCUE results as ordinal values for ROC analysis yielded additional diagnostic information (Figure 2). For example, the likelihood ratio of 1.0 (95% CI, 0.42.0) for borderline positive moderate or severe LA enlargement increased to 29 (range, 1362) for extreme positive results. Areas under the ROC curves were 0.9 for 4 out of 6 cardiac abnormalities.

Figure 2

LV systolic dysfunction and IVC dilatation were both prevalent enough to meet our criterion to examine interobserver variability; the mean number of abnormal patients per hospitalist was 10 patients for LV systolic dysfunction and 6 patients for IVC dilatation. For LV systolic dysfunction, SDs around mean sensitivity (84%) and specificity (87%) were 12% and 6%, respectively. For IVC dilatation, SDs around mean sensitivity (58%) and specificity (86%) were 24% and 7%, respectively.

Discussion

We found that, after a 27‐hour training program, hospitalists performed HCUE with moderate to excellent diagnostic accuracy for 6 important cardiac abnormalities. For example, hospitalists' assessments of LV systolic function yielded positive and negative likelihood ratios of 6.9 (95% CI, 4.99.8) and 0.2 (95% CI, 0.10.3), respectively. At the bedsides of patients with acute heart failure, therefore, hospitalists could use HCUE to lower or raise the 50:50 chance of LV systolic dysfunction30 to 15% or 85%, respectively. Whether or not these posttest likelihoods are extreme enough to cross important thresholds will depend on the clinical context. Yet these findings demonstrate how HCUE has the potential to provide hospitalists with valuable point‐of‐care data that are otherwise unavailableeither because routine clinical assessments are unreliable31 or because echocardiographic services are not immediately accessible.1

In fact, recent data from the Joint Commission on Accreditation of Healthcare Organizations shows how inaccessible SE may be. Approximately one‐quarter of hospitals in the United States send home about 10% of patients with acute heart failure without echocardiographic assessment of LV systolic function before, during, or immediately after hospitalization.32 In doing so, these hospitals leave unmet the 2002 National Quality Improvement Goal of universal assessment of LV systolic function for all heart failure patients. Hospitalists could close this quality gap with routine, 10‐minute HCUE assessments in all patients admitted with acute heart failure. (Our research HCUE protocol required a median time of 28 minutes, but this included time to assess 5 other cardiac abnormalities and collect data for research purposes). Until the clinical consequences of introducing hospitalist‐performed HCUE are studied, potential benefits like this are tentative. But our findings suggest that training hospitalists to accurately perform HCUE can be successfully accomplished in just 27 hours.

Other studies of HCUE training programs for noncardiologists have also challenged the opinion that learning to perform HCUE requires more than 100 hours of training.2, 711 Yet only 1 prior study has examined an HCUE training program for hospitalists.5 In this study by Martin et al.,5 hospitalists completed 5 supervised HCUE examinations and 6 hours of interpretation training before investigators scored their image acquisition and interpretation skills from 30 unsupervised HCUE examinations. To estimate their final skill levels at the completion of all 35 examinations by accounting for an initially steep learning curve, investigators then adjusted these scores with regression models. Despite these upward adjustments, hospitalists' image acquisition and interpretation scores were low in comparison to echocardiographic technicians and cardiology fellows. Besides these adjusted measurements of hospitalists' skills, however, Martin et al.5 unfortunately did not also report standard measures of diagnostic accuracy, like those proposed by the Standards for Reporting of Diagnostic Accuracy (STARD) initiative.33 Therefore, direct comparisons to the present study are difficult. Nevertheless, their findings suggest that a training program limited to 5 supervised HCUE examinations may be inadequate for hospitalists. In fact, the same group's earlier study of medical trainees suggested a minimum of 30 supervised HCUE examinations.9 We chose to design our hospitalist training program based on this minimum, though they surprisingly did not.5 As others continue to refine the components of hospitalist HCUE training programs, such as the optimal number of supervised examinations, our program could serve as a reasonable comparative example: more rigorous than the program designed by Martin et al.5 but more feasible than ASE level 1 training.

The number and complexity of assessments taught in HCUE training programs will determine their duration. With ongoing advancements in HCUE technology, there is a growing list of potential assessments to choose from. Although HCUE training programs ought to include assessments with proven clinical applications, there are no trials of HCUE‐directed care to inform such decisions. In their absence, therefore, we chose 6 assessments based on the following 3 criteria. First, our assessments were otherwise not reliably available from routine clinical data, such as the physical examination. Second, our assessments were straightforward: easy to learn and simple to perform. Here, we based our reasoning on an expectation that the value of HCUE lies not in highly complex, state‐of‐the‐art assessmentswhich are best left to echocardiographers equipped with SEbut in simple, routine assessments made with highly portable machines that grant noncardiologists newfound access to point‐of‐care data.34 Third, our assessments were clinically pertinent and, where appropriate, defined by cut‐points at levels of severity that often lead to changes in management. We suspect that setting high cut‐points has the salutary effects of making assessments easier to learn and more accurate, because distinguishing mild abnormalities is likely the most challenging aspect of echocardiographic interpretation.35 Whether or not our choices of assessments, and their cut‐points, are optimal has yet to be determined by future research designed to study how they affect patient outcomes. Given our hospitalists' performance in the present study, these assessments seem worthy of such future research.

Our study had several limitations. We studied physicians and patients from only 1 hospital; similar studies performed in different settings, particularly among patients with different proportions and manifestations of disease, may find different results. Nevertheless, our sampling method of prospectively enrolling consecutive patients strengthens our findings. Some echocardiographic measurement methods used by our hospitalists differed in subtle ways from echocardiography guideline recommendations.35 We chose our methods (Table 2) for 2 reasons. First, whenever possible, we chose methods of interpretation that coincided with our local cardiologists'. Second, we chose simplicity over precision. For example, the biplane method of disks, or modified Simpson's rule, is the preferred volumetric method of calculating LA size.35 This method requires tracing the contours of the LA in 2 planes and then dividing the LA volume into stacked oval disks for calculation. We chose instead to train our hospitalists in a simpler method based on 2 linear measurements. Any loss of precision, however, was balanced by a large gain in simplicity. Regardless, minor variations in LA size are not likely to affect hospitalists' bedside evaluations. Finally, we did not validate the results of our reference standard (SE) by documenting interobserver reliability. Yet, because SE is generally accurate for the 6 cardiac abnormalities under study, the effect of this bias should be small.

These limitations can be addressed best by controlled trials of HCUE‐directed care. These trials will determine the clinical impact of hospitalist‐performed HCUE and, in turn, inform our design of HCUE training programs. As the current study shows, training hospitalists to participate in such trials is feasible: like other groups of noncardiologists, hospitalists can accurately perform HCUE after a brief training program. Whether or not hospitalists should perform HCUE requires further study.

Inpatient bedside procedures are a major source of preventable adverse events in hospitals.1, 2 Unfortunately, many future inpatient physicians may lack the training3 and confidence4 to correct this problem. One proposed model for improving the teaching, performance, and evaluation of bedside procedures is a procedure service that is staffed by faculty who are experts at inpatient procedures.5 In a recent survey of internal medicine residents from our hospital, 86% (30 of 35) believed that expert supervision would improve central venous catheterization technique (Trick WE, personal communication).

Primary considerations in the development of a procedure service are the baseline demand for bedside procedures and whether a procedure service may affect this demand. Though variations in population‐based rates of some hospital procedures have been described,6, 7 there is little written on the demand for procedures performed at the bedsides of inpatients. Concomitant increases in demand and availability of other technologies810 suggest that improving the availability of bedside procedures may lead to an increase in their demand, regardless of whether such an increase benefits patients.11

Therefore, we sought to determine the impact of a bedside procedure service on the baseline number of paracenteses, thoracenteses, lumbar punctures (LPs), and central venous catheterizations (CVCs) performed on general medicine inpatients at our teaching hospital. In addition, we examined whether this service leads to more successful and safe procedure attempts.

METHODS

RESULTS

Subjects

During this 8‐week pilot study, there were 2157 admissions to the general medicine service. Among these admissions, 216 were excluded from our study because the patients did not arrive on the medical wards or were not under the care of the general medicine service for at least 6 hours before discharge or before being transferred to another service. Of the remaining 1941 admissions, 935 were to firms with the bedside procedure service available, and 1006 were to firms without the service available (Fig. 1)

Figure 1

DISCUSSION

We found that the mean number of bedside procedures increased by 48% (95% CI, 6% to 110%) from 61 to 90 per 1000 general medicine admissions when firms were offered a bedside procedure service. This suggests that a procedure service may lead to an increase in the number of procedures performed. For example, in our hospital, where 12,500 patients are admitted annually to the general medical service, 365 additional procedures per year (95% CI, 45840) may be performed if a procedure service is available. Despite this potential increase in demand, we were unable to demonstrate a parallel increase in bedside procedure success, even when the procedure service attending was directly supervising residents (Table 2). Though our conclusions may not be applicable to other settings, this study is, to our knowledge, the first to describe the demand for bedside procedures performed on general medicine inpatients at an urban teaching hospital and the first to demonstrate that this demand increases with the availability of a procedure service.

Because 86% of the observed increase in procedure attempts was due to therapeutic indications (Table 1), most of the observed difference may be due to undertreatment in the usual care cohort, overtreatment in the bedside procedure service cohort, or a combination of both. However, our study was not designed to determine if patients were undertreated because we did not review the appropriateness of physicians' decisions to not attempt procedures. And even though the bedside procedure service attending physician prospectively confirmed the appropriateness of each procedure attempt in that cohort, we did not examine what physicians' baseline treatment thresholds were or if they were lowered by the availability of the bedside procedure service.11 In other words, we cannot claim that the observed increase in procedure attempts was indicated based on patients' clinical factors. Nevertheless, the observed increase supports the important idea that discrete physician‐level decisions, in this case, whether to perform a bedside procedure, may be affected by broader system‐wide adoptions of new technologies like our bedside procedure service.12 Other nonclinical factors not observed in our study, such as fee‐for‐service compensation and variable physician‐level diagnostic and therapeutic thresholds, may also affect the rate of bedside procedures.

Our study had several limitations. We studied only one group of patients at one hospital: admissions to physicians in different settings may have different rates of bedside procedures. Our study design was observational. However, the predetermined sequential allocation of admissions and the varied assignments of the bedside procedure service during the study period should have limited selection bias. Our identification of procedure attempts, particularly in the usual care group, relied on resident physicians' self‐reports, and we cannot exclude a reporting bias. However, we believe that the daily interactions between investigators and residents from each team on the general medicine service limited the number of procedure attempts that went unrecorded. Finally, though sufficiently powered to determine our primary outcome, our study was underpowered to confirm statistical differences between firms in proportions of successfully performed procedures. For example, approximately 400 additional procedures (or more than 5000 additional admissions) would have been needed to sufficiently power the observed 9% increase in successful attempts that we observed with direct supervision by the procedure service attending (77% versus 86%; P = .64; Table 2). Our current sample size may be adequate in future research if success rates diverge as the experience of the procedure service attending increases. Though expert in performing bedside procedures, he had limited experience teaching them, particularly with the use of a hand‐carried ultrasound device. Just as there is a learning curve to gain the experience to successfully perform procedures,13 so may there be a learning curve to successfully teach procedures.14

Future research could address these limitations by more closely observing the decision‐making processes of physicians who order bedside procedures for general medicine inpatients in various settings. Our findings suggest that although patients' clinical circumstances are likely the most important consideration, nonclinical factors may also affect physicians' decisions.12 Like other multifaceted decision‐making processes of physicians,15 the complexity of this decision is important to examine because, as our pilot data suggest, a procedure service may not lead to more successful procedure attempts or reductions in the number of major complications. Although the cumulative expertise of our service or the innovative methods of training of other institutions may improve the performance of bedside procedures,5, 13 physicians' decisions about whether to order them will remain paramount, because any improvement in procedural competence will do little to reduce the relative danger of unnecessary procedures16 or the missed benefit of procedures left undone. Physicians of inpatients17, 18 should refine the indications for and anticipated benefits from these commonly performed invasive procedures.

Inpatient bedside procedures are a major source of preventable adverse events in hospitals.1, 2 Unfortunately, many future inpatient physicians may lack the training3 and confidence4 to correct this problem. One proposed model for improving the teaching, performance, and evaluation of bedside procedures is a procedure service that is staffed by faculty who are experts at inpatient procedures.5 In a recent survey of internal medicine residents from our hospital, 86% (30 of 35) believed that expert supervision would improve central venous catheterization technique (Trick WE, personal communication).

Primary considerations in the development of a procedure service are the baseline demand for bedside procedures and whether a procedure service may affect this demand. Though variations in population‐based rates of some hospital procedures have been described,6, 7 there is little written on the demand for procedures performed at the bedsides of inpatients. Concomitant increases in demand and availability of other technologies810 suggest that improving the availability of bedside procedures may lead to an increase in their demand, regardless of whether such an increase benefits patients.11

Therefore, we sought to determine the impact of a bedside procedure service on the baseline number of paracenteses, thoracenteses, lumbar punctures (LPs), and central venous catheterizations (CVCs) performed on general medicine inpatients at our teaching hospital. In addition, we examined whether this service leads to more successful and safe procedure attempts.

METHODS

RESULTS

Subjects

During this 8‐week pilot study, there were 2157 admissions to the general medicine service. Among these admissions, 216 were excluded from our study because the patients did not arrive on the medical wards or were not under the care of the general medicine service for at least 6 hours before discharge or before being transferred to another service. Of the remaining 1941 admissions, 935 were to firms with the bedside procedure service available, and 1006 were to firms without the service available (Fig. 1)

Figure 1

DISCUSSION

We found that the mean number of bedside procedures increased by 48% (95% CI, 6% to 110%) from 61 to 90 per 1000 general medicine admissions when firms were offered a bedside procedure service. This suggests that a procedure service may lead to an increase in the number of procedures performed. For example, in our hospital, where 12,500 patients are admitted annually to the general medical service, 365 additional procedures per year (95% CI, 45840) may be performed if a procedure service is available. Despite this potential increase in demand, we were unable to demonstrate a parallel increase in bedside procedure success, even when the procedure service attending was directly supervising residents (Table 2). Though our conclusions may not be applicable to other settings, this study is, to our knowledge, the first to describe the demand for bedside procedures performed on general medicine inpatients at an urban teaching hospital and the first to demonstrate that this demand increases with the availability of a procedure service.

Because 86% of the observed increase in procedure attempts was due to therapeutic indications (Table 1), most of the observed difference may be due to undertreatment in the usual care cohort, overtreatment in the bedside procedure service cohort, or a combination of both. However, our study was not designed to determine if patients were undertreated because we did not review the appropriateness of physicians' decisions to not attempt procedures. And even though the bedside procedure service attending physician prospectively confirmed the appropriateness of each procedure attempt in that cohort, we did not examine what physicians' baseline treatment thresholds were or if they were lowered by the availability of the bedside procedure service.11 In other words, we cannot claim that the observed increase in procedure attempts was indicated based on patients' clinical factors. Nevertheless, the observed increase supports the important idea that discrete physician‐level decisions, in this case, whether to perform a bedside procedure, may be affected by broader system‐wide adoptions of new technologies like our bedside procedure service.12 Other nonclinical factors not observed in our study, such as fee‐for‐service compensation and variable physician‐level diagnostic and therapeutic thresholds, may also affect the rate of bedside procedures.

Our study had several limitations. We studied only one group of patients at one hospital: admissions to physicians in different settings may have different rates of bedside procedures. Our study design was observational. However, the predetermined sequential allocation of admissions and the varied assignments of the bedside procedure service during the study period should have limited selection bias. Our identification of procedure attempts, particularly in the usual care group, relied on resident physicians' self‐reports, and we cannot exclude a reporting bias. However, we believe that the daily interactions between investigators and residents from each team on the general medicine service limited the number of procedure attempts that went unrecorded. Finally, though sufficiently powered to determine our primary outcome, our study was underpowered to confirm statistical differences between firms in proportions of successfully performed procedures. For example, approximately 400 additional procedures (or more than 5000 additional admissions) would have been needed to sufficiently power the observed 9% increase in successful attempts that we observed with direct supervision by the procedure service attending (77% versus 86%; P = .64; Table 2). Our current sample size may be adequate in future research if success rates diverge as the experience of the procedure service attending increases. Though expert in performing bedside procedures, he had limited experience teaching them, particularly with the use of a hand‐carried ultrasound device. Just as there is a learning curve to gain the experience to successfully perform procedures,13 so may there be a learning curve to successfully teach procedures.14

Future research could address these limitations by more closely observing the decision‐making processes of physicians who order bedside procedures for general medicine inpatients in various settings. Our findings suggest that although patients' clinical circumstances are likely the most important consideration, nonclinical factors may also affect physicians' decisions.12 Like other multifaceted decision‐making processes of physicians,15 the complexity of this decision is important to examine because, as our pilot data suggest, a procedure service may not lead to more successful procedure attempts or reductions in the number of major complications. Although the cumulative expertise of our service or the innovative methods of training of other institutions may improve the performance of bedside procedures,5, 13 physicians' decisions about whether to order them will remain paramount, because any improvement in procedural competence will do little to reduce the relative danger of unnecessary procedures16 or the missed benefit of procedures left undone. Physicians of inpatients17, 18 should refine the indications for and anticipated benefits from these commonly performed invasive procedures.

Inpatient bedside procedures are a major source of preventable adverse events in hospitals.1, 2 Unfortunately, many future inpatient physicians may lack the training3 and confidence4 to correct this problem. One proposed model for improving the teaching, performance, and evaluation of bedside procedures is a procedure service that is staffed by faculty who are experts at inpatient procedures.5 In a recent survey of internal medicine residents from our hospital, 86% (30 of 35) believed that expert supervision would improve central venous catheterization technique (Trick WE, personal communication).

Primary considerations in the development of a procedure service are the baseline demand for bedside procedures and whether a procedure service may affect this demand. Though variations in population‐based rates of some hospital procedures have been described,6, 7 there is little written on the demand for procedures performed at the bedsides of inpatients. Concomitant increases in demand and availability of other technologies810 suggest that improving the availability of bedside procedures may lead to an increase in their demand, regardless of whether such an increase benefits patients.11

Therefore, we sought to determine the impact of a bedside procedure service on the baseline number of paracenteses, thoracenteses, lumbar punctures (LPs), and central venous catheterizations (CVCs) performed on general medicine inpatients at our teaching hospital. In addition, we examined whether this service leads to more successful and safe procedure attempts.

METHODS

RESULTS

Subjects

During this 8‐week pilot study, there were 2157 admissions to the general medicine service. Among these admissions, 216 were excluded from our study because the patients did not arrive on the medical wards or were not under the care of the general medicine service for at least 6 hours before discharge or before being transferred to another service. Of the remaining 1941 admissions, 935 were to firms with the bedside procedure service available, and 1006 were to firms without the service available (Fig. 1)

Figure 1

DISCUSSION

We found that the mean number of bedside procedures increased by 48% (95% CI, 6% to 110%) from 61 to 90 per 1000 general medicine admissions when firms were offered a bedside procedure service. This suggests that a procedure service may lead to an increase in the number of procedures performed. For example, in our hospital, where 12,500 patients are admitted annually to the general medical service, 365 additional procedures per year (95% CI, 45840) may be performed if a procedure service is available. Despite this potential increase in demand, we were unable to demonstrate a parallel increase in bedside procedure success, even when the procedure service attending was directly supervising residents (Table 2). Though our conclusions may not be applicable to other settings, this study is, to our knowledge, the first to describe the demand for bedside procedures performed on general medicine inpatients at an urban teaching hospital and the first to demonstrate that this demand increases with the availability of a procedure service.

Because 86% of the observed increase in procedure attempts was due to therapeutic indications (Table 1), most of the observed difference may be due to undertreatment in the usual care cohort, overtreatment in the bedside procedure service cohort, or a combination of both. However, our study was not designed to determine if patients were undertreated because we did not review the appropriateness of physicians' decisions to not attempt procedures. And even though the bedside procedure service attending physician prospectively confirmed the appropriateness of each procedure attempt in that cohort, we did not examine what physicians' baseline treatment thresholds were or if they were lowered by the availability of the bedside procedure service.11 In other words, we cannot claim that the observed increase in procedure attempts was indicated based on patients' clinical factors. Nevertheless, the observed increase supports the important idea that discrete physician‐level decisions, in this case, whether to perform a bedside procedure, may be affected by broader system‐wide adoptions of new technologies like our bedside procedure service.12 Other nonclinical factors not observed in our study, such as fee‐for‐service compensation and variable physician‐level diagnostic and therapeutic thresholds, may also affect the rate of bedside procedures.

Our study had several limitations. We studied only one group of patients at one hospital: admissions to physicians in different settings may have different rates of bedside procedures. Our study design was observational. However, the predetermined sequential allocation of admissions and the varied assignments of the bedside procedure service during the study period should have limited selection bias. Our identification of procedure attempts, particularly in the usual care group, relied on resident physicians' self‐reports, and we cannot exclude a reporting bias. However, we believe that the daily interactions between investigators and residents from each team on the general medicine service limited the number of procedure attempts that went unrecorded. Finally, though sufficiently powered to determine our primary outcome, our study was underpowered to confirm statistical differences between firms in proportions of successfully performed procedures. For example, approximately 400 additional procedures (or more than 5000 additional admissions) would have been needed to sufficiently power the observed 9% increase in successful attempts that we observed with direct supervision by the procedure service attending (77% versus 86%; P = .64; Table 2). Our current sample size may be adequate in future research if success rates diverge as the experience of the procedure service attending increases. Though expert in performing bedside procedures, he had limited experience teaching them, particularly with the use of a hand‐carried ultrasound device. Just as there is a learning curve to gain the experience to successfully perform procedures,13 so may there be a learning curve to successfully teach procedures.14

Future research could address these limitations by more closely observing the decision‐making processes of physicians who order bedside procedures for general medicine inpatients in various settings. Our findings suggest that although patients' clinical circumstances are likely the most important consideration, nonclinical factors may also affect physicians' decisions.12 Like other multifaceted decision‐making processes of physicians,15 the complexity of this decision is important to examine because, as our pilot data suggest, a procedure service may not lead to more successful procedure attempts or reductions in the number of major complications. Although the cumulative expertise of our service or the innovative methods of training of other institutions may improve the performance of bedside procedures,5, 13 physicians' decisions about whether to order them will remain paramount, because any improvement in procedural competence will do little to reduce the relative danger of unnecessary procedures16 or the missed benefit of procedures left undone. Physicians of inpatients17, 18 should refine the indications for and anticipated benefits from these commonly performed invasive procedures.