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Acquiring Procedural Skills in ICUs: A Prospective Multicenter Study*

Roux, Damien MD, PhD1,2; Reignier, Jean MD, PhD3; Thiery, Guillaume MD4; Boyer, Alexandre MD, PhD5; Hayon, Jan MD6; Souweine, Bertrand MD7; Papazian, Laurent MD, PhD8; Mercat, Alain MD9; Bernardin, Gilles MD10; Combes, Alain MD, PhD11; Chiche, Jean-Daniel MD, PhD12; Diehl, Jean-Luc MD13; du Cheyron, Damien MD, PhD14; L’Her, Erwan MD, PhD15; Perrotin, Dominique MD16; Schneider, Francis MD17; Thuong, Marie MD18; Wolff, Michel MD19; Zeni, Fabrice MD20; Dreyfuss, Didier MD1,2; Ricard, Jean-Damien MD, PhD1,2

doi: 10.1097/CCM.0000000000000049
Clinical Investigations

Objectives: Providing appropriate training of procedural skills to residents while ensuring patient safety through trainee supervision is a difficult and constant challenge. We sought to determine how effective and safe procedural skill acquisition is in French ICUs and to identify failure and complication risk factors.

Design: Multicenter prospective observational study. Invasive procedures performed by residents were recorded during two consecutive semesters.

Setting: Eighty-four residents.

Subjects: Eighty-four residents.

Intervention: None.

Measurements and Main Results: Number of invasive procedures performed, failure and complication rates, supervision, and assistance provided. Five thousand six hundred seventeen procedures were prospectively studied: 1,007 tracheal intubations, 1,272 arterial and 2,586 central venous catheter insertions, 457 fiberoptic bronchoscopies, and 295 chest tube insertions. During the semesters, residents performed a median of 10 intubations, 14 arterial catheter insertions, and 26 central venous catheter insertions. Complication rates were low, similar to those in the literature: 8.6% desaturation and 7.4% esophageal placement during intubation; 0.4% and 2.3% pneumothorax with jugular and subclavian central venous catheter insertions, respectively. We identified risk factors for failure and complications. Higher rates of failure and complications for intubation were associated with residents with no or little previous experience (p < 0.001); failure of internal jugular vein catheterization was associated with left-side insertion (p = 0.005) and absence of mechanical ventilation (p = 0.007). Supervision and assistance were more frequent at the beginning of the semester and for intubation and chest tube insertion. Finally, residents had less access to fiberoptic bronchoscopy and chest tube insertion.

Conclusion: Procedural skills acquisition by residents in the ICU appears feasible and safe with complication rates comparable to what has previously been reported. We identified specific procedures and situations associated with higher failure and complication rates that could require proactive training. Questions still remain regarding minimal numbers of procedures to attain competence and how best to provide procedural training.

Supplemental Digital Content is available in the text.

1AP–HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France.

2UMRS-722, Univ Paris Diderot, Sorbonne Paris Cité, UMRS-722, Paris, France.

3Service de Réanimation Polyvalente, CHD Les Oudaries, La Roche sur Yon, France.

4AP–HP, Hôpital Saint-Louis, Service de Réanimation Médicale, Paris, France.

5Service de Réanimation Médicale, Hôpital Pellegrin-Tripode, CHU Bordeaux, Bordeaux, France.

6Service de Réanimation Polyvalente, CHI Poissy-Saint-Germain en Laye, site de Saint-Germain, Saint-Germain en Laye, France.

7Service de Réanimation, CHU, Clermont Ferrand, France.

8Service de Réanimation Médicale, Hôpital Sainte Marguerite, Marseille, France.

9Service de Réanimation Médicale, CHU Angers, Angers, France.

10Service de Réanimation Médicale, CHU Nice, Nice, France.

11AP–HP, Hôpital Pitié-Salpétrière, Service de Réanimation Médicale, Paris, France.

12AP–HP, Hôpital Cochin, Service de Réanimation Médicale, Paris, France.

13AP–HP, Hôpital Européen Georges Pompidou, Service de Réanimation Médicale, Paris, France.

14Service de Réanimation Médicale, Hôpital de la Côte de Nacre, Caen, France.

15Service de Réanimation Médicale, Hôpital de la Cavale Blanche, Brest, France.

16Service de Réanimation Médicale, CHU Tours, Tours, France.

17Service de Réanimation Médicale, CHU de Strasbourg, Strasbourg, France.

18Service de Réanimation Polyvalente, Hôpital Delafontaine, Saint-Denis, France.

19AP–HP, Hôpital Bichat, Service de Réanimation Médicale, Paris, France.

20Service de Réanimation Médicale et Polyvalente Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne, France.

* See also p. 994.

Drs. Roux, Reignier, Dreyfuss, and Ricard made substantial contributions to the intellectual content of the article in terms of conception and design, acquisition of data, drafting of the manuscript, statistical analysis, and supervision. Drs. Thiery, Boyer, Hayon, Souweine, Papazian, Mercat, Bernardin, Combes, Chiche, Diehl, du Cheyron, L’Her, Perrotin, Schneider, Thuong, Wolff, and Zeni made substantial contributions to the intellectual content of the article in terms of acquisition of data, critical revision of the manuscript for important intellectual content, and supervision. Dr. Ricard states that he had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Boyer consulted for Coviden and received support for travel from Pfizer and MSD. His institution received grant support from Teleflex. Dr. Souweine received support for the development of educational presentations from Gilead and Laboratoire Français du Fractionnement et des Biotechnologies and received support for meeting expenses from Pfizer. His institution received grant support from Bayer Sante and AstraZeneca and has a patent planned for 2014. Dr. Papazian provided expert testimony for Faron, received grant support from Association Régionale d’Assistance Respiratoire à Domicile, and received support for travel from Air Liquide Santé. Dr. Mercat consulted for Faron Pharmaceuticals, received grant support from Covidien and General Electric, and received support for travel from Maquet and Covidien. His institution has patent with General Electric. Dr. L’Her and his institution have patent with Oxynov and have stock options with Oxynov (three patents are pending; Dr. L’Her is one of the founders). Dr. Wolff served as a board member for Cubist; consults for Novartis, Astellas, and Gilead; and lectures for Novartis, Astellas, and Gilead. Dr. Dreyfuss’s institution received grant support from Pfizer. Dr. Ricard served as a board member for Covidien and received support for travel from Fisher and Paykel and lectured for Covidien. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins