Chest tube placement is used when there is an accumulation of air or fluid in the pleural space and needs to be evacuated quickly, which can be life-saving.1 This procedure is especially important for significant traumatic pneumothoraces because it is life-threatening and has the potential for complications.2 Without practice, complications can occur such as delayed placement, inadequate placement, infection, laceration of the lung, or placing the tube into a solid organ or into the abdomen.1 A study in 2009 found that of 273 patients with a chest tube, or in need of one, there were 26 complications relating to insertion and positioning of the chest tube; however, with training, these can be minimized.3
Any emergency healthcare provider must learn many different procedural skills including chest tube insertion; however, there may not be many opportunities to perform this. This is a stressful event and lack of confidence can have bad outcomes.4 Repeating a skill multiple times has been shown to improve speed, retention of the skill, and performance under pressure.5 Training programs have tried to use dogs, cats, pigs,6 and human cadavers to teach this procedure.7 However, using animal and cadaver models can produce difficulties with storage and use and may not provide the best simulation. Many task trainers that have been created, such as using mannequins covered with a biomaterial,8 to more commercialized task trainers such as TraumaMan.9 Previously described nonbiologic custom-made task trainers are complex in design and require technical molding and casting procedures.10 Beyond the initial sculpting, model creation can also require stocking polymer material to make a casting negative and final resin based shell. Such methods require extensive time and effort on the part of the healthcare simulation technology specialist to produce anatomically accurate models. Although commercial chest tube simulators have been found to be good for finding landmarks,11 they may not provide the level of realism for effective skill acquisition.10
Task trainers are important because they allow for practice and can provide similar feedback; however, these training devices can be costly, costing up to $US 3000 initially and up to US $50 per learner in disposable materials. As such, it was important to create a model that is cost-effective, easy to store, quick to setup, effective at training, durable, and not inferior to current training methods. The purposes of this article are to teach how to create a Chest tube High-feedback Educational Simulation Trainer (CHEST) and to report feedback received on this model.
This study consists of two phases. Phase 1 describes the construction of the model. Phase 2 describes feedback reporting of survey data.
Phase 1: Simulator Construction
A chest wall shell was created using PVC and wood. Using a 10 × 8-in piece of 1/2-inch thick plywood, a 1/4-in-deep notch was cut along the long side of the plywood, approximately a half inch from the edge. A similar notch was added to a 10-in-long 2 × 6 along the long edge. The 2 × 6 was affixed to the top of the plywood at a 90-degree angle using screws, so that the notches were away from the vertex but facing each other. A 3/4-in diameter PVC pipe was quartered using a band saw. Each quarter was cut to a length of 9 1/2 in with about a 15-degree angle at each end to create rib segments. Five ribs were placed into the notches on either end with 1/4 in spacing in-between each rib. The ribs were secured using wood glue. The end of each rib was flattened using pliers to place into the notches, rounded side out (Fig. 1). Fifteen task trainers were created by two study designers in two 4-hour sessions.
Once the chest frame was created, different tissue layers were needed to complete the model. Three separate foam layers were designed to fit the chest frame (Fig. 2). The three tissue layers represented muscle, adipose, and skin tissue. The muscle layer was designed from COHRlastic silicone foam rubber 500 duro 0.062-in thickness in a red color.12 The skin layer was designed from BISCO silicone foam HT-820 0.125-in thickness.13 The adipose layer was designed from polyurethane foam (Polyether 1034) at 0.5-in thickness.14 Each of these had a peel-and-stick adhesive for rapid attachment to the top of the chest frame (Fig. 3, materials).
Phase 2: Simulator Function Evaluation
Once the task trainer was created, testing sites were recruited to participate in the evaluation of the model at the national emergency medicine residency program leadership conference (CORDEM) through face-to-face discussions. Eight emergency medicine residency programs and one advanced paramedic flight training school agreed to participate without compensation. Each site was provided a task trainer and multiple tissue layers to accommodate the expected number of learners at each institution. In addition to the chest frame and tissue samples, a USB drive with two training videos, one video teaching setup and maintenance of the task trainer (see Video, Supplemental Digital Content 1, https://links.lww.com/SIH/A407, showing the setup and use of tissue layers to assemble the CHEST model for use) and a second video teaching the chest tube insertion skill were provided. In addition, a procedural checklist for recommended evaluation of procedure performance was also included. Educators at each of these sites were identified and sent surveys for both learner and proctor feedback about the training model. Participant learners included emergency medicine residents and advanced paramedic flight trainees. Proctors were emergency medicine attending physicians at each program site and a senior flight medic instructor at the paramedic flight training school instructional sessions.
The learner survey contained 14 items evaluating the realism and effectiveness for chest tube insertion training. Ten items assessed usability with responses on a five-point scale ranging from strongly disagree to strongly agree (Table 1). Four additional items assessed learner preferences about the model design. The proctor survey contained 29 items that included four open-ended questions about benefits, weaknesses, and improvements for the model. The remaining items used a Likert scale and multiple-choice responses to collect information on the effectiveness of training, comparison with other training devices, and aspects for logistics and use (Tables 2, 3). Each site was asked to return anonymous surveys once evaluation of the model was completed. Sites were allowed to keep the chest frame and any remaining tissues for continued use. This study was reviewed by an institutional review board and classified as exempt. Completion of the voluntary and anonymous survey constituted consent for participation.
After receiving the completed surveys back from each of the testing sites, raw data were consolidated into an Excel sheet. Descriptive statistics including percentages, means, and frequencies were calculated using SPSS Version 23.
Initially 10 institutions agreed to participate, only nine sites returned data for analysis. Of these sites, all nine returned learner surveys (n = 159); however, only seven sites returned proctor surveys (n = 11). This discrepancy in proctor survey numbers is due to some sites having multiple proctors participating in training. Learners attested to being able to use the skin layer 4 or more times (73%, n = 115), the fat layer 4 or more times (78%, n = 123), and the muscle layer 4 or more times (76%, n = 120). Sixty-two percent (n = 90) of the learners believed the fat layer to be the right thickness, whereas 35% (n = 55) thought that it was too thin. Table 1 provides the response percentages for various aspects of the model including questions related to realism and effectiveness.
Overall, most learners agreed or strongly agreed that the model provided a realistic cut for skin and fat layers, hemostat puncture and spread through the muscle layer, and finger sweep. The majority also agreed that the model allowed for proper training of tube placement, skin suturing, and tube securing. Eighty-three percent (n = 132) agreed that the CHEST trainer was a good method of training this technical skill.
Eleven proctor surveys came from seven institutions. Proctor responses stated that they were able to use the skin layer 4 or more times (73%, n = 8), use the fat layer 4 or more times (73%, n = 8), and use the muscle layer 4 or more times (73%, n = 8). Table 2 provides proctor responses to items related to effectiveness of the CHEST.
Table 3 provides proctor responses to items related to realism, cleanup, storability, and durability of the CHEST in comparison with other chest tube task trainers. In addition, six proctors (60%) responded that they used the provided procedural checklist during their instruction of the procedure.
The majority found that skin cutting, blunt dissection, muscle layer puncture, and tube insertion were effective. One area that was identified as weaker than the others related to the skin layer suturing and tube securing. No rib or wood failures were reported. Nine proctors responded about the time it took to change the tissue layers. Four reported that they could change the layers in less than 1 min, three reported the process took between 1 and 2 minutes, and two needed between 2 and 5 minutes to complete the tissue layer exchange. Ninety-one percent of the proctors surveyed stated that they would use this task trainer if it was at an equal or lesser cost than other chest tube task trainers.
This product was well reviewed by learners and proctors and serves as an improvement to current training models by offering a smaller and less expensive task trainer which still offers realistic demonstration of skin cutting, muscle puncture, and blunt dissection. The skin layer was found to tear easily during suture and limited training of tube securing; future studies are planned to evaluate a foam layer with increased density to improve training of this skill. The higher density BISCO HT-840 is being considered as a more durable alternative.13 As another option to mitigate this limitation and to improve upon the current design, simulation sites may choose to modify the skin layer by adding Power Mesh or a similar fabric substrate. Power Mesh can be added between the skin and muscle layers or incorporated into a custom-made outer skin layer, similar to a suture pad. This design is used in other task trainers to minimize tearing when suturing.10,15,16 Learners had a mixed response to the thickness of the adipose tissue. This tissue was half an inch thick and still much thicker than current task training models. Even so, it was still viewed to be too thin by a third of respondents. The fat layer was intentionally made thicker than current models to make rib palpation difficult and train dissection and tunneling. This technique is not currently trainable in noncadaveric models. Because layers are individually selected and attached, individual sites could select a different thickness for the fat layer to improve perceived realism for their learner and patient population. Although other models have used standalone frames, many of these use animal tissue that requires accommodation such as refrigeration, cleaning, and in some institutions biohazard disposal.17
Cost of Construction
The bulk of the expense for this task trainer is from the cost of the different tissue layers. Cost for the layers was US $15.75 for a set of three layers, and pricing was decreased with bulk purchasing that may not be available for individual centers. The tissue layers could be used by approximately 4 learners per fresh set. The cost per learner for the CHEST is found to be approximately US $3.93. Estimated cost for current training techniques from our surveys was reported at US $20 to $50 per learner. Other costs to be considered are the time for material acquisition and construction that are not frequently considered with other do-it-yourself projects. Consider that assembly would likely take several hours even for a single model to be created and there was some added efficiency with repetitive model construction. Costs of the individual layers for the muscle, fat, and skin respectively were US $6.90, $1.95, and $6.90.
Many other training devices have been developed to show effective training of chest tube insertion, with many other methods reported at being effective. This may demonstrate that there is not one superior method, but rather many beneficial methods to provide this type of training. Although a large number of learners were sampled and 11 proctor surveys were collected, only seven sites provided proctor feedback—with some sites returning surveys from multiple proctors. Although the surveys distributed were anonymous by participant, they were categorized by institution, and thus, some bias may have been introduced with concern for opinions about negative feedback.
A task trainer can be easily made using simple shop tools and materials. This task trainer was found to be easy to store, quick to set up, durable, easy to clean, and rated as effective at training the skill of chest tube insertion. It is important to have this skill ready whenever a critical patient may arrive, and this can be used to help train and keep a health care provider ready.
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