This article was downloaded by: [Ryerson University] On: 27 April 2015, At: 04:21 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum a
b
a
Shawna Shafer , Deborah Rooney , Robert Schumacher & Joseph B. House
c
a
Division of Neonatal/Perinatal Medicine, University of Michigan, Ann Arbor, Michigan, USA
b
Department of Medical Education, University of Michigan, Ann Arbor, Michigan, USA
c
Division of Pediatric Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Published online: 20 Apr 2015.
Click for updates To cite this article: Shawna Shafer, Deborah Rooney, Robert Schumacher & Joseph B. House (2015) Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum, Teaching and Learning in Medicine: An International Journal, 27:2, 205-207, DOI: 10.1080/10401334.2014.979185 To link to this article: http://dx.doi.org/10.1080/10401334.2014.979185
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 27(2), 205–207 C 2015, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.979185
Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum Shawna Shafer Division of Neonatal/Perinatal Medicine, University of Michigan, Ann Arbor, Michigan, USA
Deborah Rooney Department of Medical Education, University of Michigan, Ann Arbor, Michigan, USA
Robert Schumacher Division of Neonatal/Perinatal Medicine, University of Michigan, Ann Arbor, Michigan, USA
Joseph B. House Downloaded by [Ryerson University] at 04:21 27 April 2015
Division of Pediatric Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
Keywords Issue: Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents’ rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor. Evidence: A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm3, and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm3 and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm3 (n = 71). Implications: We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.
medical education, needs assessment, pediatrics, neonatal
BACKGROUND Pediatric residents commonly perform lumbar punctures (LPs) during their clinical training. Competency and assessment of this procedural skill is not uniformly evaluated across institutions, even though the Accreditation Council for Graduate Medical Education (ACGME) requires that pediatric residents are proficient in performing this procedure.1 In previous research, Auerbach and colleagues found that residents typically begin their postmedical school training with little more than passive exposure to LPs.2 The authors further suggested that many residents are not adequately proficient in achieving nontraumatic LPs, despite the importance of this skill.2 Increased risk of a traumatic LP has been attributed to a number of factors, and recent literature suggests that low practitioner experience is a primary factor.3,4 Conroy et al. found that 30% of 1st-year residents and 24% of 2nd-year residents failed to meet baseline competency in performing an LP.3 The ACGME provides no objective guidance for defining proficiency. Presumably a LP is a diagnostic procedure done for the purposes of obtaining spinal fluid of sufficient quantity and quality to allow for further diagnostic testing. In addition, adequate documentation of the procedure is required. In this chart review, we focused on two factors that should indicate deficiencies in the performance of LPs: incomplete/inaccurate documentation and residents’ lack of proficiency (as measured by the number of attempts and the presence of sufficient sample size free of excessive numbers of red blood cells (RBC), i.e., >1000). Traumatic LPs are those producing Correspondence may be sent to Shawna Shafer, Neonatal/Perinatal containing >1000 RBC/mm3, as this Medicine, University of Michigan, 8–621 Mott Hospital, 1540 East cerebrospinal fluid (CSF) 5 Hospital Drive, SPC 4254, Ann Arbor, MI 48109–4254, USA. E-mail: is the visual threshold. Based on clinical observations, [email protected] tions of this review were that the majority of LPs performed by 205
206
S. SHAFER, D. ROONEY, R. SCHUMACHER, J. B. HOUSE
TABLE 1 Results of chart review Step
n (%)
Improper Documentation No Documentation in Chart Inadequate Sample Acquisition >1000 RBC/mm3 >3 Attempts at Procedure
106 (58%) 14 (8%) 39 (23%) 84 (64%) 11 (14%)
Downloaded by [Ryerson University] at 04:21 27 April 2015
Note: Total charts reviews = 184. RBC = red blood cells.
residents in an academic Level 4 Neonatal Intensive Care Unit (NICU) were traumatic and that many of the samples of CSF obtained were inadequate for laboratory analysis. In addition, we expected that documentation of the procedure was poor, potentially leading to an inaccurate representation of a patient’s clinical course. Using order codes specific to CSF testing, all medical charts of infants admitted to the NICU who underwent an LP procedure between January 2011 and November 2011 were retrospectively reviewed. Charts were initially evaluated for completion of proper documentation. Documentation was considered complete if it contained the following information: patient name, medical record number, purpose of the procedure, person performing the procedure, description of the procedure, the total number of attempts to obtain fluid, the type of analgesia used, complications, and patient tolerance. Procedure and progress notes were reviewed in the patient’s chart. If not documented, it was assumed that the individual who completed the progress note also conducted the procedure. This assumption is likely largely accurate because attending physicians and neonatology fellows rarely conduct lumbar punctures in this NICU. Resident proficiency was then assessed using three surrogate measures in a stepwise fashion after reviewing procedure and progress notes in the patient’s chart: 1. Rate of obtaining a CSF sample that was of adequate volume and not clotted. TABLE 2 Well-documented lumbar punctures (n = 78): Average RBC count ± standard deviation No. of Attempts 1 2 3 4+
Total Sample No.
Samples Analyzed
M RBC
SD
29 23 16 10
26 18 10 7
10000 54737 79253 24773
4172 1376447 164545 24677
Note: Sample separated by number of attempts and then again by number of samples that were analyzed, as in several cases no sample was obtained or the volume was too low for analysis. RBC = red blood cells.
2. Rate of obtaining a CSF sample that contained a RBC of
Teaching and Learning in Medicine: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/htlm20
Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum a
b
a
Shawna Shafer , Deborah Rooney , Robert Schumacher & Joseph B. House
c
a
Division of Neonatal/Perinatal Medicine, University of Michigan, Ann Arbor, Michigan, USA
b
Department of Medical Education, University of Michigan, Ann Arbor, Michigan, USA
c
Division of Pediatric Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA Published online: 20 Apr 2015.
Click for updates To cite this article: Shawna Shafer, Deborah Rooney, Robert Schumacher & Joseph B. House (2015) Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum, Teaching and Learning in Medicine: An International Journal, 27:2, 205-207, DOI: 10.1080/10401334.2014.979185 To link to this article: http://dx.doi.org/10.1080/10401334.2014.979185
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Teaching and Learning in Medicine, 27(2), 205–207 C 2015, Taylor & Francis Group, LLC Copyright ISSN: 1040-1334 print / 1532-8015 online DOI: 10.1080/10401334.2014.979185
Lumbar Punctures at an Academic Level 4 NICU: Indications for a New Curriculum Shawna Shafer Division of Neonatal/Perinatal Medicine, University of Michigan, Ann Arbor, Michigan, USA
Deborah Rooney Department of Medical Education, University of Michigan, Ann Arbor, Michigan, USA
Robert Schumacher Division of Neonatal/Perinatal Medicine, University of Michigan, Ann Arbor, Michigan, USA
Joseph B. House Downloaded by [Ryerson University] at 04:21 27 April 2015
Division of Pediatric Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
Keywords Issue: Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents’ rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor. Evidence: A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm3, and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm3 and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm3 (n = 71). Implications: We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.
medical education, needs assessment, pediatrics, neonatal
BACKGROUND Pediatric residents commonly perform lumbar punctures (LPs) during their clinical training. Competency and assessment of this procedural skill is not uniformly evaluated across institutions, even though the Accreditation Council for Graduate Medical Education (ACGME) requires that pediatric residents are proficient in performing this procedure.1 In previous research, Auerbach and colleagues found that residents typically begin their postmedical school training with little more than passive exposure to LPs.2 The authors further suggested that many residents are not adequately proficient in achieving nontraumatic LPs, despite the importance of this skill.2 Increased risk of a traumatic LP has been attributed to a number of factors, and recent literature suggests that low practitioner experience is a primary factor.3,4 Conroy et al. found that 30% of 1st-year residents and 24% of 2nd-year residents failed to meet baseline competency in performing an LP.3 The ACGME provides no objective guidance for defining proficiency. Presumably a LP is a diagnostic procedure done for the purposes of obtaining spinal fluid of sufficient quantity and quality to allow for further diagnostic testing. In addition, adequate documentation of the procedure is required. In this chart review, we focused on two factors that should indicate deficiencies in the performance of LPs: incomplete/inaccurate documentation and residents’ lack of proficiency (as measured by the number of attempts and the presence of sufficient sample size free of excessive numbers of red blood cells (RBC), i.e., >1000). Traumatic LPs are those producing Correspondence may be sent to Shawna Shafer, Neonatal/Perinatal containing >1000 RBC/mm3, as this Medicine, University of Michigan, 8–621 Mott Hospital, 1540 East cerebrospinal fluid (CSF) 5 Hospital Drive, SPC 4254, Ann Arbor, MI 48109–4254, USA. E-mail: is the visual threshold. Based on clinical observations, [email protected] tions of this review were that the majority of LPs performed by 205
206
S. SHAFER, D. ROONEY, R. SCHUMACHER, J. B. HOUSE
TABLE 1 Results of chart review Step
n (%)
Improper Documentation No Documentation in Chart Inadequate Sample Acquisition >1000 RBC/mm3 >3 Attempts at Procedure
106 (58%) 14 (8%) 39 (23%) 84 (64%) 11 (14%)
Downloaded by [Ryerson University] at 04:21 27 April 2015
Note: Total charts reviews = 184. RBC = red blood cells.
residents in an academic Level 4 Neonatal Intensive Care Unit (NICU) were traumatic and that many of the samples of CSF obtained were inadequate for laboratory analysis. In addition, we expected that documentation of the procedure was poor, potentially leading to an inaccurate representation of a patient’s clinical course. Using order codes specific to CSF testing, all medical charts of infants admitted to the NICU who underwent an LP procedure between January 2011 and November 2011 were retrospectively reviewed. Charts were initially evaluated for completion of proper documentation. Documentation was considered complete if it contained the following information: patient name, medical record number, purpose of the procedure, person performing the procedure, description of the procedure, the total number of attempts to obtain fluid, the type of analgesia used, complications, and patient tolerance. Procedure and progress notes were reviewed in the patient’s chart. If not documented, it was assumed that the individual who completed the progress note also conducted the procedure. This assumption is likely largely accurate because attending physicians and neonatology fellows rarely conduct lumbar punctures in this NICU. Resident proficiency was then assessed using three surrogate measures in a stepwise fashion after reviewing procedure and progress notes in the patient’s chart: 1. Rate of obtaining a CSF sample that was of adequate volume and not clotted. TABLE 2 Well-documented lumbar punctures (n = 78): Average RBC count ± standard deviation No. of Attempts 1 2 3 4+
Total Sample No.
Samples Analyzed
M RBC
SD
29 23 16 10
26 18 10 7
10000 54737 79253 24773
4172 1376447 164545 24677
Note: Sample separated by number of attempts and then again by number of samples that were analyzed, as in several cases no sample was obtained or the volume was too low for analysis. RBC = red blood cells.
2. Rate of obtaining a CSF sample that contained a RBC of
