Simulation Improves Procedural Protocol Adherence During Central Venous Catheter Placement

Abstract

Background Simulation training may improve proficiency at and reduces complications from central venous catheter (CVC) placement, but the scope of simulation’s effect remains unclear. This randomized controlled trial evaluated the effects of a pragmatic CVC simulation program on procedural protocol adherence, technical skill, and patient outcomes. Methods Internal medicine interns were randomized to standard training for CVC insertion or standard training plus simulation-based mastery training. Standard training involved a lecture, a video-based online module, and instruction by the supervising physician during actual CVC insertions. Intervention-group subjects additionally underwent supervised training on a venous access simulator until they demonstrated procedural competence. Raters evaluated interns’ performance during internal jugular CVC placement on actual patients in the medical intensive care unit. Generalized estimating equations were used to account for outcome clustering within trainees. Results We observed 52 interns place 87 CVCs. Simulation-trained interns exhibited better adherence to prescribed procedural technique than interns who received only standard training (p=0.024). There were no significant differences detected in first-attempt or overall cannulation success rates, mean needle passes, global assessment scores or complication rates. Conclusions Simulation training added to standard training improved protocol adherence during CVC insertion by novice practitioners. This study may have been too small to detect meaningful differences in venous cannulation proficiency and other clinical outcomes, highlighting the difficulty of patient-centered simulation research in settings where poor outcomes are rare. For high-performing systems, where protocol deviations may provide an important proxy for rare procedural complications, simulation may improve CVC insertion quality and safety.

Central venous catheterization training: current perspectives on the role of simulation

“… 27 , 28 In a randomized-controlled trial of 52 interns, those who were simulation-trained demonstrated better adherence to prescribed procedural technique than did traditionally trained interns who received a didactic lecture, online module with video, had time dedicated to familiarization with the checklist, and supervised practice. 24 Similar improvements to protocol adherence after simulation-based education have been replicated. 27 Recent studies have used first needle pass success and failed needle pass attempts as a “pass/fail” modality and have shown improvement in this endpoint after simulation-based ultrasound-guided CVC.…”

“…Notably, only three of these studies are randomized controlled trials. 24 – 26 All of the studies used either commercially available mannequins, homemade trainers, animal models, computer software, or virtual reality programs. The studies all included a control group that had not received a simulation-based training intervention.…”

The association between implementation of second-tier prevention practices and CLABSI incidence: A national survey

“…22 Simulation programs have been found to increase skill of performance, enhance confidence and reduce the risk of complications at the time of insertion. 23 A number of studies have assessed the impact of simulation-based training on CLABSI rates. [24][25][26] The use of simulations of central venous catheter (CVC) insertion significantly reduced CLABSI rates compared with those in control wards.…”

Practical guide for safe central venous catheterization and management 2017

“…Real-time ultrasound catheterization can visualize both target vein and needle during the procedure. To achieve this skill, simulation training is effective [5,6]; however, enough training should be needed to achieve the skill. Institutions and hospitals should introduce the use of mannequins and other educational equipment for puncture simulations.…”

“…Factors that can increase moderate levels of risk include (1) puncturing the site of a previous central venous catheterization, (2) history of local radiation therapy, (3) history of median sternotomy, (4) recent myocardial infarction, (5) thrombocytopenia, (6) venous thrombosis at the puncture site, (7) fibrinolytic therapy, and (8) an anxious patient. Factors that can increase mild levels of risk include (1) abnormal weight/height ratio, (2) severe obesity, (3) prolonged coagulation time, (4) artificial respiration with high airway pressure, (5) moderate to severe arteriosclerosis, (6) sepsis, (7) ventricular arrhythmia, (8) pulmonary emphysema or chronic obstructive pulmonary disease, and (9) hypovolemia [59].…”