key: cord-1016486-wucnwjaq
authors: Koubek, Richard; Brady, Anna; Gopalratnam, Kavitha; Oeckler, Richard; Kennedy, Cassie C.; Kelm, Diana
title: Virtual Procedural Supervision during the COVID-19 Pandemic: A Novel Pilot for Supervising Invasive Bedside Procedures in the ICU
date: 2021-09-21
journal: Mayo Clin Proc Innov Qual Outcomes
DOI: 10.1016/j.mayocpiqo.2021.09.003
sha: 07517aca53955b231d19bde2748a8de41f8f03f0
doc_id: 1016486
cord_uid: wucnwjaq

The ability to perform invasive bedside procedures (IBPs) safely and efficiently is a core skillset within critical care medicine. Fellowship training provides a pivotal time for learners to attain baseline proficiency in such procedures to decrease patient complications. The COVID-19 pandemic has posed distinct challenges to the traditional model of teaching and supervising IBPs in the intensive care unit (ICU), including stewardship of personal protective equipment (PPE) and limiting healthcare worker exposure to persons with COVID-19. To address these challenges, we piloted a novel method of IBP supervision and teaching utilizing a virtual monitoring system. In this virtual procedural supervision model, the supervising teacher is located outside of the patient room, limiting PPE utilization and healthcare worker exposure. An audio-visual monitoring system allowed communication between teacher and learner, and supervisor visualization of the procedural encounter. Virtual supervision was utilized for central line placement and bronchoscopy in the medical ICU with no complications or instances of the supervisor needing to enter the patient room. Success was felt to depend on camera positioning, pre-procedure planning, and to be best for advanced learners who would not require tactile feedback. Upper level learners appreciated autonomy granted by this process. Virtual IBP supervision is felt to be a useful tool in specific situations. As with any tool, there are notable strengths and limitations. Success is felt to be optimized when attention is paid to procedural teaching best practices, learner selection, and technological logistics.

The ability to perform invasive bedside procedures (IBPs) safely and efficiently is a core skillset within critical care medicine. Fellowship training provides a pivotal time for learners to attain baseline proficiency in such procedures to decrease patient complications. The COVID-19 pandemic has posed distinct challenges to the traditional model of teaching and supervising IBPs in the intensive care unit (ICU), including stewardship of personal protective equipment (PPE) and limiting healthcare worker exposure to persons with COVID-19.

To address these challenges, we piloted a novel method of IBP supervision and teaching utilizing a virtual monitoring system. In this virtual procedural supervision model, the supervising teacher is located outside of the patient room, limiting PPE utilization and healthcare worker exposure. An audio-visual monitoring system allowed communication between teacher and learner, and supervisor visualization of the procedural encounter.

Virtual supervision was utilized for central line placement and bronchoscopy in the medical ICU with no complications or instances of the supervisor needing to enter the patient room. Success was felt to depend on camera positioning, pre-procedure planning, and to be best for advanced learners who would not require tactile feedback. Upper level learners appreciated autonomy granted by this process.

Virtual IBP supervision is felt to be a useful tool in specific situations. As with any tool, there are notable strengths and limitations. Success is felt to be optimized when attention is paid to procedural teaching best practices, learner selection, and technological logistics. To address the challenges listed above, we piloted a novel method of IBP supervision in the ICU using remote video monitoring wherein the supervising provider observes and communicates with the learner performing the procedure via a mobile tablet-based camera system (In Touch Telehealth). There is precedent for use of virtual supervision, with successful implementation in J o u r n a l P r e -p r o o f urology (7), emergency department care (8) rural settings, and primary care (9), however without extensive literature regarding use in critical care-based procedural training. Also, there may also be utility for routine use in transition to independent practice (10). As example, a majority of urology residents who underwent virtual supervision during endourologic procedures felt remote monitoring should be standard practice in residency training (7) .

In this pilot, learners were fellow level trainees enrolled in PCCM and Critical Care Internal

Medicine fellowship programs at Mayo Clinic in Rochester, MN. Supervisors were boardcertified critical care faculty working in the medical ICU, the designated hospital COVID unit.

Supervisors were stationed immediately outside of the room to allow for their timely availability in case of emergency, while limiting exposure and PPE use. Table 1 describes the participant and encounter details.

The investigator created structured interview questions sent via e-mail to supervisor and learner participants ( Table 2 ) for assessment of their experience utilizing this method of virtual IBP supervision. Input was also supplemented through unstructured interviews approximating the structured e-mail interview questions. Qualitative input was collected from four supervisors and two learners, a 100% response rate from faculty and 66% response rate from fellows who engaged in virtual supervision. The structured e-mail questionnaire was completed by 50% of J o u r n a l P r e -p r o o f supervisors and 33% of learners. Investigators reviewed results of the structured interview questions and unstructured interviews using thematic analysis to determine themes.

We identified five categories or themes related to virtual supervision: Teamwork, comfort, procedural preparation, autonomy, and technology limitations.

Supervisor participants noted the role of additional team members such as respiratory therapy or nursing to ensure success of the virtual supervision. This was primarily related to manipulating the camera to allow visualization of key parts of the procedure. 

Being alone in a room for the first time performing a procedure, makes you kind of nervous. This made the "band-aid" pull slightly easier.  Learner #1

The majority of supervisors found this model to be successful, especially when appropriate camera position was achieved prior to the procedure. Camera position training was suggested for those responsible for positioning the tablet throughout the procedure.

The key is positioning of the unit by [respiratory therapy] or someone in the room... if the unit is not positioned correctly, I could see you not having a view at all.  Supervisor #2

Learners did appreciate the autonomy offered by performing the procedure "independently"

without the supervisor directly in the room as a graduated transition from learner to independent practice. Based on our findings, situated in literature, we suggest specific tips and practices to promote success of virtual IBP teaching and supervision (Table 3) . For example, preparation was deemed essential in the success of this procedure. This includes being familiar with any limitations in technology or audio-visual system, which may require assistance from additional team members to overcome. Literature support the pre-brief as a key step in effective IBP teaching (11) . The pre-brief also provides opportunity for a critical step in virtual supervision, learner selection. As discussed above, virtual supervision is felt to be best suited for learners approaching or ready for independent practice. It is therefore important to effectively assess a learner's zone of proximal development prior to proceeding (12) . This can in part be completed by asking the learner to talk aloud through each step of the procedure during the pre-brief.

Evidence-based procedural teaching models such as the Briefing-Intraprocedure Teaching-Debriefing can still be utilized effectively (13) to provide a structured approach to the procedural teaching. In particular, the briefing is felt to be particularly important in virtual supervision. Not only does this allow the ability to discuss the virtual supervision process and appropriate camera positioning, but also development of a plan should the learner ultimately require in-person assistance.

In summary, based on our experience with this pilot intervention, virtual IBP supervision and teaching may be an appropriate and useful tool in specific situations. Success is felt to be optimized when specific attention is paid to procedural teaching best practices, learner selection, and technological logistics.

J o u r n a l P r e -p r o o f

Acquiring procedural skills in ICUs: a prospective multicenter study*

ACGME Program Requirements for Graduate Medical Education in Pulmonary Disease and Critical Care Medicine (Subspecialty of Internal Medicine)

Central venous catheterization training: current perspectives on the role of simulation

The impact of inhouse attending surgeon supervision on the rates of preventable and potentially preventable complications and death at the start of the new academic year

Supervision by a technically qualified surgeon affects the proficiency and safety of laparoscopic colectomy performed by novice surgeons

Summary for Healthcare Facilities: Strategies for Optimizing the Supply of PPE during Shortages cdc

Impact of remote monitoring and supervision on resident training using new ACGME milestone criteria

Virtual Remote Attending Supervision in an Academic Emergency Department During the COVID-19 Pandemic

Remote Supervision in Primary Care during the Covid-19 pandemic -the "new normal

Twelve tips on how to set up postgraduate training via remote clinical supervision

Characteristics of Effective Teachers of Invasive Bedside Procedures: A Multi-institutional Qualitative Study

Mind in Society: The Development of High Psychological Processes: Harvard University Pr

J o u r n a l P r e -p r o o f Are there any changes you would recommend for future procedures performed using this supervision model?As a fellow, in what ways did this effect your learning?Are there any changes you would recommend for future procedures performed using this supervision model?J o u r n a l P r e -p r o o f