Do More With Less: A Surgery Directed Institutional Model for Resident Central Line Training

David Leshikar, M.D.Jonathan Pierce, M.D.Edgardo Salcedo, M.D.Gurpreet Bola, B.S.Joseph Galante, M.D.April 23, 2013

“See One, Do One, Teach One”

• Apprenticeship model• Little to no supervision• Bedside teaching

Simulation Training

• Background

• Uses• Procedural training• CPR/ACLS• Endoscopy• Laparoscopy• Endovascular

• Fundamentals of Laparoscopic Surgery

Central Venous Catheters (CVC)

• Common bedside procedure• Performed by many specialties• Complications

Central Line Simulation

• CVC Simulation:• Decreases complications• Improves comfort level

• Widespread adoption

Barsuk, et al, Crit Care Med, 2009. Barsuk, et al, Arch Intern Med, 2009Burden, et al, J Clin Anesth, 2012.

Procedural Simulation

• Expensive• Equipment costs• Faculty time

• No standardized assessment metrics

• Redundant within institutions

Duncan, et al, J Grad Med Educ, 2010

Hypothesis

• A curriculum centralized in the department of surgery • Single faculty trainer• Maintain quality of training • Institution wide• Efficient resource utilization

Curriculum

• Web-based module• Covered all aspects of central line

placement• Pre/Post testing

• Hands-on simulation training• Technical training – all components• Video assessment

Resource Utilization

• Equipment costs• CVC simulator• Simulator supplies

• Staff productivity• Number of faculty involved• Preparation time

• Compared pre vs post implementation

Pre-Implementation

• Individual departments• Inconsistent simulator use• No standardization

Post-Implementation

• Study Period: July 2010-June 2012• Departments involved:

• Surgery• Internal Medicine• Emergency Medicine• Family Practice• Pediatrics• Anesthesia

• Standardized evaluation• Single faculty trainer

Online Module

  July 2010 – June 2011 July 2011 – June 2012

  N= 132 N = 126

Pre-Test Mean 7.0 7.1

Post-Test Mean 8.4 8.4

Difference +1.4 +1.3

P value < 0.0001 < 0.0001

Video Assessments

  PGY-1 PGY-2 PGY-3 PGY-4+

  N=26 N=9 N=5 N=1

Pre-Test Mean 14.2 15.0 12.8 15.0

Post-Test Mean 17.5 15.4 14.8 17.0

Difference +3.3 +0.4 +2.0 +2.0

P value 0.0001 0.426 0.0217  

Central Line Infections

Mean before, 3.8 infections per 1000 catheter daysMean after, 2.3 infections per 1000 catheter days

Resource Utilization  Pre-Implementation Post-Implementation

Residents Per Session 1-5 3-5

Simulators Used 5 (4 manufacturers) 2 (single manufacturer)

CVC Kits 1 per session 1 per 10 sessions

Attending Participation Variable Standardized

Attending Preparation Variable Standardized

Facility Preparation Not standardized Standardized

Estimated Program Costs  Pre-Implementation Post-Implementation

Supply Costs        

CVC Simulator 5 models ($1500) $7,500 2 models ($1500) $3,000

Maintenance 4 manufacturers   Single manufacturer  

CVC Kits 1 per session ($100) $2600 1 per 10 sessions ($100) $260

         

Staff Productivity        

Attending Physicians 10   1  

Preparation Time 30 min x 26 sessions 13 hours None  

Sim Lab Staff        

Setup 4 manufacturers Single manufacturer  

Faculty Familiarity 10 different attendings Single attending  

Summary

• Streamlined development• Effective instruction• Improved efficiency

Conclusion

• Standardization of simulation• Maintained quality of teaching• Decrease resource utilization

Questions?