PICU fellow entrustment: How do faculty make supervision decisions?

Affiliations

Advocate Children's Hospital/Park Ridge

Abstract

Introduction

Academic faculty make supervision decisions which balance the goals of trainee competency with patient safety. Previous work shows significant variability and potential bias in these entrustment decisions. Given the high stakes, understanding how these decisions are made is vital. Qualitative studies established traits that influence entrustment decisions, but the relative contribution of each has not been described. We aim to characterize the influence of these traits on entrustment decisions for Pediatric Critical Care Medicine (PCCM) fellows.

Methods

We surveyed faculty who supervise PCCM trainees at three PCCM departments. Based on 8 vignettes, faculty chose the level of supervision for a fellow performing an endotracheal intubation- direct or indirect supervision with the attending, direct or indirect supervision of a fellow supervising a junior trainee, or unsupervised. Each vignette varied by 3 traits: 1) patient condition 2) trainee-supervisor relationship and 3) trainee experience. There was a 72% response rate (n=51/70). We created a logistic regression model using the 3 traits and faculty attributes (gender, primary unit, education role) as predictors of direct supervision. We also compared faculty attributes for those selecting direct supervision for e4 cases andFischer's exact test and Wilcoxon Rank Sum.

Results

The majority of vignettes (78%, 311/396) were rated direct supervision. Of vignettes with a 3rd year fellow, 59% (118/199) were rated direct supervision compared with 97% (193/197) for a 1st year. Trainee-supervisor relationship, patient status and primary unit were significant predictors of direct supervision in the regression model. Compared with cardiac ICU faculty, the odds ratio for pediatric ICU faculty to entrust fellows was 2.27 (95% CI 1.07-4.81) and 4.68 (95% CI 1.54-14.19) for mixed cardiac/pediatric ICU faculty. Odds ratios were 2.14 (95% CI 1.47-3.12) for 1 week on service with the fellow (ref: never worked together) and 0.09 (95% CI 0.04-0.17) for a rapidly deteriorating patient (ref: stable patient). Faculty selecting direct supervision for e or < 4 cases did not differ significantly.

Conclusion

PCCM entrustment decisions are influenced by the patient's condition, supervisor's relationship with the trainee and supervisor's primary unit.

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Article

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