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
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?