The use of the central venous catheter (CVC) has become an indispensable resuscitation tool in the emergency department and intensive care unit. However, CVC placement has risks including both mechanical and infectious complications of insertion.1–5 Previous studies have shown that more than 15% of patients who receive a CVC experience one or more complications.6–8
Many system improvements have been postulated in an attempt to decrease these risks.9 The Institute for Healthcare Improvement has proposed the “Central Line Bundle,”10 which includes ultrasound guided placement and full sterile barrier precautions during insertion. Although adherence to the Central Line Bundle should decrease the number of complications, providing training and experience for all physicians involved in CVC placement can be difficult. Traditionally, such experience has come entirely from patient encounters, potentially putting patients at risk, especially with junior trainees. Procedure complication rates are inversely related to the experience of the operator. Although the exact number of times a procedure must be performed to develop sustained competency is unclear, operators who have placed more than 50 CVCs have fewer complications than those who have placed fewer than 50 CVCs.7,8 Given that most house staff (including fellows) have placed far fewer than 50 CVCs and to decrease risk to patients as trainees acquire this experience, there is a need to safely improve learning methods to shorten the learning curve.
Current focus on quality improvement, innovation, and patient safety has increased the use of simulation-based instructional methods, especially in settings associated with significant patient risk.11 A simulation-based, multispecialty Central Line Workshop (CLW) was developed at the Multidisciplinary Simulation Center to offer trainees a safe, experiential learning opportunity for CVC placement. This 4-hour curriculum on ultrasound-guided CVC placement has been offered to residents and fellows involved with CVC insertion since 2005 and has been required of all emergency medicine (EM) residents since 2008. Residents demonstrate competency to perform the procedure safely and effectively in a simulated environment before being allowed to place CVCs on actual patients.
Recent studies have shown improved performance after simulation-based CVC training.12–19 Skill decay has been shown to occur over time after training sessions, and skill retention is improved with deliberate practice.19–25 We predicted that the CLW would improve performance of CVC placement for EM residents. Although some skill decay at 3 months after the CLW was anticipated, our primary aim was to determine if there is sustained improvement compared with the baseline assessment before the CLW. Secondarily, we sought to determine variability in the performance after the CLW based on the level of experience with CVC placement.
The Mayo Clinic Institution Review Board approved this prospective observational cohort study, which was conducted at a teaching hospital with a multidisciplinary simulation center. The EM residency is a 3-year program with 8 to 9 residents each year. The Accreditation Council for Graduate Medical Education requires EM graduates to have placed a minimum of 20 CVCs, whereas the Mayo Clinic EM residency requires 30 CVCs before graduation. Because of perceived benefits to patients, the CLW is a requirement for each EM resident; therefore, no control group was available.
To measure the impact of CLW training, between November 2008 and May 2009, each EM resident’s central line procedure skill was assessed 3 months before CLW (T1), immediately on completion of CLW (T2), and 3 months after CLW (T3) (Fig. 1). Three-month assessment intervals were chosen to allow assessment of skill decay while completing the study before advancement of residents to the next academic year. The baseline skill assessment (T1) was part of an annual simulation-based competency assessment course with residents unaware that CVC placement would be included.
Approximately 3 months after T1 (average, 100 days; range, 82–119 days), each resident was scheduled for the CLW (T2). Before the CLW, each resident completed online prerequisites including a combination of literature review and a case-based self-study module. The CLW has previously been described in detail.26 Residents participated in interactive learning stations (ultrasound station, gloving and gowning station, and a procedural skill laboratory, both cadaveric and with a CVC task trainer) with hands-on teaching and deliberate practice. Experiential practice was followed by reflective debriefing with an EM attending faculty or respiratory therapist specifically trained to instruct the CLW. Finally, each resident performed a simulated internal jugular vein (IJ) CVC placement uninterrupted followed by instructions to obtain isolated subclavian vein (SC) venipuncture (without repeating other items assessed on the checklist). The session concluded with individualized instructor debriefing of the assessment station and an additional opportunity to demonstrate missed items from the checklist.
Approximately 3 months after the CLW course (T3; average, 109 days; range, 91–127 days), residents were retested at the simulation center. Similar to T1, residents did not know they would be undergoing assessment of CVC placement before arrival, as it was included during a regularly scheduled simulation-based educational session.
For all T1, T2, and T3 assessments, residents were given identical instructions at the time of the testing to place a CVC in accordance with institutional policy on a simulated task trainer (Blue Phantom, Redmond, WA). Identical assessment stations involving both IJ and SC catheterization were used. Video of each resident’s performance was captured and rated by investigators (Y.D. and H.S.S.) who had no previous exposure to the residents and were blinded to their level of training. We previously confirmed high interrater agreement (88.9%) using a validated assessment instrument, the Central Venous Catheterization Proficiency Scale for scoring (Table 1).26,27 The score was calculated as the percentage of 15 dichotomous items performed correctly. In a previous study of 105 participants, the checklist was able to demonstrate high score reliability and discriminate levels of trainee experience in CVC proficiency.26 We measured procedure time from the initial greeting of the “patient” until successful insertion of the IJ CVC. We did not include the SC venipuncture in the procedure time. During the study period, each resident continued to self-report and record every central line placed in a required procedure log. The residents had no additional simulated central line training or performance between testing sessions (T1, T2, and T3).
The composite performance and number of procedures were summarized as a median (range). The Kruskal-Wallis test was used for comparison among postgraduate year (PGY) groups followed by a pairwise Wilcoxon rank sum tests between two groups. Two-sided 5% type 1 error was used to determine statistical significance. All statistical analyses were performed using statistical software package JMP 8.0 (SAS Institute Inc, Cary, NC).
A total of 26 residents were enrolled in the study (Table 2). Because of schedule conflicts, one resident missed the T2 assessment station, whereas 3 did not participate in session T3; however, the assessment stations they attended were included in the overall data set. Figure 2 and Table 3 show the composite scores for each session with Table 3 revealing time to insertion of the IJ CVC. After the CLW, there was overall improvement of the performance score. The median performance composite scores were improved (0.6 vs. 0.93, P < 0.001) after the CLW with no change in median procedure time (20.4 vs. 20.4 minutes). However, performance decay was noted after CLW (T3) compared with CLW. The 3 items demonstrating the largest drop from T2 to T3 include (percent score at T2 vs. T3): “hand hygiene” (92% vs. 35%); “procedural pause” (96% vs. 57%), and “preprocedure ID verification” (80% vs. 57%). Although the post-CLW scores were lower than those at the CLW, there was an overall improvement in the performance score compared with the baseline (0.8 vs.0.6, P < 0.05), and the procedure times were shorter but did not reach statistical significance (19.0 vs. 20.4 minutes, P = 0.2).
When stratifying the residents by training year, PGY3 residents self-report placement of more CVC lines than PGY1 residents during the study period (5.5 vs. 1.5, P < 0.001) (Table 4). The baseline performance of PGY2 and PGY3 residents was significantly higher than that of PGY1 residents. There were no significant differences between groups for the performance improvement at T2 and decay at T3 for the PGY1 and PGY2 residents. Figure 3 shows composite scores by PGY of training. The PGY1 group showed greater improvement compared with the PGY2 and PGY3 groups in the median performance score after the CLW training with the effect lasting more than 3 months (Table 5).
The format of the CLW, constructed around the principles of Bloom’s taxonomy,28 proved highly effective in achieving predefined learning objectives. Performance was assessed using a previously validated assessment instrument checklist, which is able to discriminate levels of trainee experience and has been shown to have high scoring reliability.26 In an effort to standardize best practices across specialties within the institution, the items on the checklist (Table 1) were chosen prospectively by a multidisciplinary team to include key elements of proper technique while seeking to reduce both mechanical and infectious complications of CVC placement.
CVC line placement by EM residents was substantially improved after the CLW, similar to results reported by others.12–19 Composite scores decreased in the 3 months after the CLW, but scores after CLW remained higher than baseline. The appearance of skill decay during the 3 months after CLW has been demonstrated previously19 and may suggest a need for more frequent deliberate practice after the CLW. The skill decay was equal among the novice and senior residents, despite the senior residents performing more CVC placements between sessions. The items demonstrating the largest decay 3 months after the CLW include hand hygiene, procedural pause, and preprocedure ID verification. Given the high risk of complications for CVC placement in the emergency department, these items are important to ensure patient safety and potentially decrease complications such as infection and placement in the wrong site or patient. Future research should identify curricula that maintain sustained gains on these items.
Proper reinforcement of skills through deliberate practice is critical to maintain competency at all levels. Whether the baseline to post-CLW improvement is from the CLW or from additional clinical experience is unclear. It is possible that repeated exposure to the CLW might better maintain competency, but this must be balanced by the resources required for such a simulated experience. With consideration of the previous experience of the residents, our study also revealed that the biggest performance gain was observed for those with less CVC experience. The novice learners (PGY1) have more performance improvement through simulation-based CVC training. Despite less experience and lower baseline scores, the PGY1 residents performed nearly identically to the PGY2 and PGY3 residents at the time of the CLW and sustain a similar level of performance 3 months after the CLW (Fig. 3). The CLW may have the greatest impact on patient safety improvement for the most novice trainees. CLW seems to accelerate the procedural performance of novice learners, diminishing the performance gaps between the PGY1 and more senior residents.
Our study has several limitations. First, it is limited to a single center with a small sample size, and the results might be different with larger populations and different programs. Second, there was no control group without CLW training to compare with the simulation group. Third, although the checklist was designed to ensure standardization of best practices across specialties, one could argue that not all components of the checklist used for scoring are of equivalent importance. Finally, we did not assess clinical performance because there might be performance gaps between simulation-based assessment and clinical practice.29
Our study is unique in that residents were unaware that CVC placement would be assessed before arrival to the baseline and post-CLW assessment sessions (T1 and T3), thus eliminating the opportunity to specifically prepare before the testing session and making this design generalizable for other similar studies. This allowed assessment truly reflective of each resident’s skill level and not a manifestation of a testing scenario. We also captured the baseline characteristics and improvement variations between learners, enabling us to explore different course designs in the future to be tailored to a learner’s level of experience. Further studies are needed to investigate the ideal frequency and method of reinforcement for CVC placement to most efficiently improve clinical care.30,31
With the use of experiential learning through simulation, the CLW improved EM resident CVC placement performance. Skill decay did occur during the study period, but there was improvement in CVC placement at 3 months after the CLW compared with baseline performance. The improvement is greatest for learners who have placed fewer CVCs in actual patients, with performance of novices after CLW approaching that of more experienced learners without increased rates of decay. Providing a simulation-based CLW experience before CVC placement on clinical rotations allows novice learners to learn without risk and may enhance patient safety. Future study should focus on approaches to maintain competency over time and optimize the skill transfer from the simulation setting to clinical practice.
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