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Does training level affect the accuracy of visual assessment of capillary refill time?
Critical Care volume 23, Article number: 157 (2019)
Capillary refill time (CRT) measured at the bedside is widely promulgated in critical care and intensive care medicine [1, 2]. However, traditional CRT measurements are relatively subjective , and the accuracy is questionable given that clinicians use the naked eye to perform these visual assessments [4, 5]. The purpose of our study was to evaluate the accuracy of visually assessed CRT among observers who have different training levels.
Fingernail compression and release videos were recorded from patients in the emergency department (ED) at a suburban, quaternary care teaching hospital in New York. We used our image analysis software to analyze the corresponding fingernail video to calculate patient’s CRT (Fig. 1). Nine clinicians and two non-clinicians voluntarily participated as observers to review the videos. Videos from 20 patients were displayed on a screen three times in random order, for a total of 60 videos. The observers watched each fingernail video and pressed a time switch when they deemed the fingernail color had returned to its baseline state. The truth of visually assessed CRT was evaluated by using a correlation of the numbers between the image analysis and the visual assessment. We also sought to determine the intra-observer reliability to evaluate the precision of visual assessments.
Image analysis of CRT of 20 ED patients ranged from 0.47 to 7.98 s, with a mean of 2.44 ± 2.09 s. The highest intra-observer reliability among the three visual assessment times was displayed by one of the physician assistants (0.70 for single measure and 0.88 for average measures); however, it was also as low as 0.15 for a single measure and 0.34 for average measures by one of the non-clinicians. Intra-observer reliability was the highest in attending physicians and physician assistants, followed by residents, nurses, and non-clinicians. The mean intra-observer reliability of the clinicians was higher than the non-clinicians (0.46 vs. 0.25, p < 0.05). Figure 2 shows intra-observer reliability of the video assessment as a function of correlation coefficient of video CRT assessment with image CRT analysis. Observers, who showed a higher correlation with image CRT analysis, demonstrated higher intra-observer reliability, and there was a strong correlation between these coefficient values (r = 0.72, p < 0.05).
Visual assessment of CRT is variable. Personal work experience may help improve both truth and precision of CRT assessments and increase the accuracy among individual observers. Therefore, training level appears to be an important factor that affects the reliability of visual CRT assessment.
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Research reported in this publication was supported by the research grant of Nihon Kohden Corporation.
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The study protocol was approved by the Institutional Review Board (no. 17-0805). Informed consent for participation was obtained from all patients prior to the completion of any study procedures.
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LSJ, JMF, TL, and JK have no known conflicts of interest associated with this study, and there has been no significant financial support for this work that could have influenced its outcome. Kota S., NK, and SW are employees of Nihon Kohden Corporation and Nihon Kohden Innovation Center, INC. There are no products in market to declare. This does not alter the authors’ adherence to all the journal’s policies on sharing data and materials. Koichiro S. and LBB have a patent right of metabolic measurements in critically ill patients. Koichiro S. has a grant/research support from Nihon Kohden Corp.. LBB has a grant/research support from Philips Healthcare, the NIH, Nihon Kohden Corp., Zoll Medical Corp, PCORI, BrainCool, and United Therapeutics and owes patents including 7 issued patents and several pending patents involving the use of medical slurries as human coolant devices to create slurries, reperfusion cocktails, and measurement of respiratory quotient.
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Shinozaki, K., Jacobson, L.S., Saeki, K. et al. Does training level affect the accuracy of visual assessment of capillary refill time?. Crit Care 23, 157 (2019). https://doi.org/10.1186/s13054-019-2444-3