ABC | Volume 114, Nº1, January 2019

Original Article Aimoli & Miranda STEMI Management by Recently Graduated Physicians Arq Bras Cardiol. 2020; 114(1):35-44 The development of the checklist The checklist was developed by a cardiologist with experience in treating STEMI patients following the V Guideline of the Brazilian Society of Cardiology on Acute Myocardial Infarction Treatment with ST-Segment Elevation and revised by other five experienced physicians. 6 The checklist included 12 different items, six of which were directly concerned with the treatment (0.5 points each, with a total of 3.0 points): requirement of ECG monitoring, insertion of a peripheral venous access catheter, acetylsalicylic acid administration, administration of a second antiplatelet agent (p2y12 inhibitor), sublingual nitrate administration and morphine administration (it was not necessary to specify the correct dosage of these medications, but only to mention them). And the six remaining items were directly associated with the diagnosis and transfer management: recognition of the diagnosis of STEMI (2.0 points), assessment of pain duration, which is an important aspect in the determination of the therapeutic conduct in this case (1.0 point), recognition of immediate need for patient transfer (2.0 points) in order to perform reperfusion therapy (thrombolytic or primary angioplasty), one item related with communication skills towards the patient, explaining the disease and the treatment using simple and objective language (1.0 point) and one item related with reinforcing the need to transfer the patient for a tertiary service, even in case of non‑availability of beds (1.0 point), defined as “zero vacancy”, according with the Resolution 2077/14 of the Federal Medicine Council (CFM) for urgencies and emergencies. Finally, there was one item of negative evaluation, which consisted of delaying treatment to wait for myocardial necrosis markers (a two-point reduction in the score). More details on the checklist can be found in Appendix C* of the supplementary appendix. The score ranged from 0 to 10 points, being directly proportional to the clinical competence observed in the simulated scenario approach. According to the organization of the checklist, the most important items were: identification of STEMI diagnosis (2.0 points) and immediate transfer to reperfusion (2.0 points). In relation to the correct diagnosis, it was necessary to specify ST-segment elevation, because electrocardiographic criteria for this diagnosis are quite well defined. We considered as a partial answer the identification of infarction with no reference to ST‑segment elevation, since, even in such case, the applicant could initiate the recommended therapeutic conduct. Other drug therapies were included as adjuvant therapy and had the same value (0.5 points), since all of them were classified as Class-I recommendation in the most recent Brazilian guidelines for initial management of STEMI. Demographic and education data These data were obtained from the application form filled out by the candidates: age, sex, graduation year, state of origin, medical school of origin. Data related to the performance in the evaluation, obtained through the electronic checklist, were exported to Excel spreadsheets from a system exclusively developed to carry out this practical assessment. This project was approved by the Ethics Committee in Research of our institution under protocol number 838/2017. Statistical Analysis Sample size corresponded to all the applicants who performed the station practical exam of the selection process for the medical residency program of the HC-FMRP-USP, in 2016. Normality of distribution was checked using the Shapiro‑Wilk test. Quantitative variables with normal distribution were expressed as mean (standard deviation) and the other quantitative variables as median and interquartile range. Categorical variables were expressed as percentage. Student‑t test was used to compare two quantitative variables with normal distribution and Mann-Whitney test was used for comparison between two quantitative variables not normally distributed. The Chi-square test was used to compare two categorical values. A two-tailed p-value < 0.05 was considered significant. Data analyses and graphic building were performed by STATA 13.1 for Windows (STATA software, College Station, TX, USA). Results The demographic characteristics of the 771 applicants who performed the tasks in this simulated station are shown in Table 1. The median age was 25 years (24-27 years), and the majority of the applicants were males (58%). Most applicants were newly formed physicians (90%), among whom 71% had graduated less than a year before and 19% had graduated between 1-2 years before. Most candidates had come from a public university (66%) in the Southeast region (65%). Regarding the general performance of the applicants, a median of 7.0 (interquartile range: 5.5-8.0) and a mean of 6.74 with a standard deviation of 1.93 were observed (Figure 2). In relation to each item of the checklist directly associated with the treatment, the following result was observed: 83% of the applicants requested ECG monitoring, 57% oriented the insertion of a peripheral venous access device, 95% administered acetylsalicylic acid, 80% added a second antiplatelet agent (P2Y12 inhibitor), 66% administered sublingual nitrates e 71% administered intravenous morphine for pain relief (Figure 3). The following proportion was observed in relation to the checklist items concerning with the diagnosis and transfer management: 69% of the applicants identified the diagnosis of STEMI and 28% identified the diagnosis of infarction, but did not mention ST-segment elevation. The duration of pain was verified by 71% of the applicants. The majority of the applicants recognized the need for transfer to perform the reperfusion procedure (63%) and 19% recognized this necessity, however they did not specify the reason for the transfer (reperfusion therapy), 18% did not raise the need for transfer. Communication skills were considered adequate in 34% of the applicants (they provided adequate explanation on disease and treatment), 32% explained only one of these items (disease or treatment) and 34% did not approach any of the two items with the patient. Only 25% of the applicants insisted on the transfer to a tertiary center even in case of non-availability of beds after the actor’s intervention. A total of 4% of the applicants kept waiting for the markers of myocardial necrosis in order to define the therapeutic conduct (Figure 4). 37