making procedures safe(r) central line insertion paul currier, md, mph mgh pulmonary & critical...
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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
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Financial Disclosures: None
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Central Venous AccessComplications
Puncture of Artery
Collapsed Lung
Air in Vessel
Abnormal Heart Rhythm
Infection
Blood Clot
Death
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Safety Interventions……
Policy
Education
Procedure Modifications – structural and forcing functions
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Proven Policy Interventions
Hand Washing
Full Barrier Precautions
Chlorhexidine
Avoiding Femoral Site
Removing Unnecessary Catheters
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How to Teach Procedures?
1. Classic Mentoring: Watch Someone, try it on a patient
2. Instructional Videos
3. Simulation
4. Animal Models
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Mentoring Model
Dependent on Individual Variation
Dependent on Clinical Opportunity
High Risk Learning
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Impact of Videos on Procedural Training
• 210 Medical Residents
• NEJM Videos on Arterial Catheter & Central Line Placement
• Pre-test, procedure, post-test
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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
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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)
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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
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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
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Circumplex Model of Emotion: Russell and Feldman Barrett, 1999
Emotionality of the Experience is the Difference
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Central Venous Catheter Insertion
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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
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“Great program! All interns should do this
before the MICU, even after a few lines”
“Small group training was perfect!”
Resident Commentary
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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
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Suturing
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