Making Procedures Safe(r)Central Line Insertion

Paul Currier, MD, MPHMGH Pulmonary & Critical Care Unit

Associate Program Director for Procedures and Critical Care Education, DOM

Instructor in Medicine, Harvard Medical School

Financial Disclosures: None

Central Venous AccessComplications

Puncture of Artery

Collapsed Lung

Air in Vessel

Abnormal Heart Rhythm

Infection

Blood Clot

Death

Safety Interventions……

Policy

Education

Procedure Modifications – structural and forcing functions

Proven Policy Interventions

Hand Washing

Full Barrier Precautions

Chlorhexidine

Avoiding Femoral Site

Removing Unnecessary Catheters

How to Teach Procedures?

1. Classic Mentoring: Watch Someone, try it on a patient

2. Instructional Videos

3. Simulation

4. Animal Models

Mentoring Model

Dependent on Individual Variation

Dependent on Clinical Opportunity

High Risk Learning

Impact of Videos on Procedural Training

• 210 Medical Residents

• NEJM Videos on Arterial Catheter & Central Line Placement

• Pre-test, procedure, post-test

Improving Residents’ Knowledge of Medical Procedures Using a Video-Based Curriculum: A

Randomized Trial

Baseline scores on knowledge tests low:

– 58 % arterial lines

– 62 % central lines

Improving Residents’ Knowledge of Medical Procedures Using a Video-Based Curriculum: A

Randomized Trial

Small but significant increase with videos:

– 58 % arterial lines 70% (p<0.0001)

– 62 % central lines 66% (p=0.01)

A Definition of Simulation

Healthcare simulation is an educational and training method (tool) that creates real world experiences allowing learners to acquire knowledge and skills in an observed risk free environment to improve care and promote safety. Simulation occurs in concert with other teaching modalities to enhance safe, efficient, competent care.

As created by the MGH Simulation Task Force. Some slides based on presentations by MGH Simulation Task Force members to the MGH Trustees Education Subcommittee, the MGH Council on Technology Adoption and Innovative Process Promotion (CTAIPP); and the

Partners GME 2010 Task Force

Why Simulation in Healthcare? What is the Added Value Over the Status Quo?

• Patient Safety: Practice Without Risk– Early exposure and competence

• Education On-Demand: Standardization of Curriculum– Mitigate time and chance

• Efficiency in a New Era: Acceleration of the Expertise Curve– A new paradigm

Circumplex Model of Emotion: Russell and Feldman Barrett, 1999

Emotionality of the Experience is the Difference

Central Venous Catheter Insertion

Post Central Line Simulation Surveys

Rate your confidence in being able to place a central line prior to this session?

1 2 3 4 5 6 7 8 9

No confidence Extremely confident

Rate your confidence in being able to place a central line after this session?

1 2 3 4 5 6 7 8 9

No confidence Extremely confident

Rate the ability of this training session to teach central line placement:

1 2 3 4 5 6 7 8.1 9 Poor Excellent

Rate the realism of this simulation:

1 2 3 4 5 6 7.2 8 9

Not realistic Extremely Realistic

“Great program! All interns should do this

before the MICU, even after a few lines”

“Small group training was perfect!”

Resident Commentary

16 Surgical Residents Randomized to VR Training or Control Until Expert Criteria Met

VR Residents: 29% Faster, Errors 6 X Less Likely to Occur

Non-VR Trained Residents: 5 X More Likely to Injure the GB or Burn Non-target Tissue

Suturing