The residents who were trained for internal jugular (IJ) and subclavian (SC) CVC insertions received two two-hour education sessions consisting of a lecture, ultrasound training, deliberate practice, and feedback. A 27-item checklist was drafted to measure outcomes; all pre- and post-tests were graded by a single unblended instructor to ensure accuracy. According to the study:
- None of the residents met the minimum passing score (MPS) of 79.1% for CVC insertion at baseline: mean IJ=48.4%, standard deviation=23.1; mean SC=45.2%, standard deviation=26.3;
- All residents met or exceeded the MPS at testing after simulation training: mean IJ=94.8%, standard deviation=10.0; mean SC=91.1%, standard deviation=17.8 (P<0.001);
- In the MICU, simulator-trained residents required fewer needle passes to insert a CVC than traditionally trained residents: mean=1.79, standard deviation=1.0 vs. mean=2.78, standard deviation=1.77 (P=0.04);
- Simulator-trained residents displayed more self-confidence about their procedural skills: mean=81, standard deviation=11 vs. mean=68, standard deviation=20 (P=0.02).
Dr. Barsuk isn’t surprised that confidence increases with training, saying “they hammer this home.” There were several categories for which the authors found no major improvement, though, even with the addition of deliberate training and standardized didactic materials.
Notably, the authors wrote, the resident groups “did not differ in pneumothorax, arterial puncture, or mean number of CVC adjustments.” Some of the lack of disparity was attributed to the small sample size.
In interviews, the authors noted that additional study would help assess such clinical outcomes as reduced CVC-related infections after simulation-based training. Still, Dr. Barsuk says, this pilot report is an important first step to win over skeptics.
“Simulation-based training and deliberate practice in a mastery learning setting improves performance of both simulated and actual CVC insertions by internal medicine residents,” the study reads. “Procedural training remains an important component of internal medicine training although internists are performing fewer invasive procedures now than in years past. Use of a mastery model of CVC insertion requires that trainees demonstrate skill in a simulated environment before independently performing this invasive procedure on patients.”
Another advantage of the training, McGaghie says, is that it helps physicians track their own improvement. He cautions against administrators using the data for more nefarious purposes, lest the testing become unpopular and less useful to quality improvement programs.
“You don’t use these evaluations as a weapon; you use them as a tool,” McGaghie says. “No one is there to beat up the doctors; no one is there to make them look foolish. The whole idea is to be as rigorous as possible to look for improvement—constant improvement.” TH
Richard Quinn is a freelance writer based in New Jersey.