Emergency Department Thoracotomy: Development of a Reliable, Validated Checklist for Procedural Training

Emergency department thoracotomy (EDT) is a rare and challenging procedure. Emergency medicine (EM) residents have limited opportunities to perform the procedure in clinical or educational settings. Standardized, reliable, validated checklists do not exist to evaluate procedural competency. The objectives of this project were twofold: 1) to develop a checklist containing the critical actions for performing an EDT that can be used for future procedural skills training and 2) to evaluate the reliability and validity of the checklist for performing EDT.

After a literature review, a preliminary 22-item checklist was developed and disseminated to experts in EM and trauma surgery. A modified Delphi method was used to revise the checklist. To assess usability of the checklist, EM and trauma surgery faculty and residents were evaluated performing an EDT while inter-rater reliability was calculated with Cohen's kappa. A Student's t-test was used to compare the performance of participants who had or had not performed a thoracotomy in clinical practice. Item-total correlation was calculated for each checklist item to determine discriminatory ability.

A final 22-item checklist was developed for EDT. The overall inter-rater reliability was strong (κ = 0.84) with individual item agreement ranging from moderate to strong (κ = 0.61 to 1.00). Experts (attending physicians and senior residents) performed well on the checklist, achieving an average score of 80% on the checklist. Participants who had performed EDT in clinical practice performed significantly better than those that had not, achieving an average of 80.7% items completed versus 52.3% (p < 0.05). Seventeen of 22 items had an item-total correlation greater than 0.2.

A final 22-item consensus-based checklist was developed for the EDT. Overall inter-rater reliability was strong. This checklist can be used in future studies to serve as a foundation for curriculum development around this important procedure.