The Impact of Central Line
Simulation Prior to ICU
Experience
1.
2.
Rebecca C. Britt MD1
T.J. Novosel MD1
LD Britt MD, MPH1
Maura Sullivan PhD, MSN2
Department of Surgery, Eastern Virginia Medical School
Department of Surgery, University of Southern California
Introduction



Classic dogma of “see one, do one, teach one”
has been challenged due to changes in health
care environment, particularly regarding
concerns for patient safety.
Apprenticeship model leads to wide variation of
skill sets that are taught.
Residents are frequently uncomfortable with this
model, especially when performing invasive
skills.
Introduction


Partial task simulators designed to teach central
line placement on a mannequin prior to
performing the task on patients recently
designed.
Several studies have examined the impact of
supervised training on resident central line
performance, but no study has shown the
effectiveness of a partial task simulator for this
skill.
Purpose

This study was designed to prospectively
evaluate whether resident performance when
placing central lines is improved following
simulation training on the partial task simulator
CentralLineMan ® (Simulab). Additionally, we
assessed whether patient outcomes were
impacted by resident simulation.
Methods



Prospective, randomized trial of standard
training, defined as apprentice model with senior
resident or fellow supervising, versus simulated
training using the partial task simulator.
Both groups received a standard lecture on
central line placement.
Statistical analysis done using MedCalc® software
for comparison of proportions and chi-squared
analysis. Significance defined as p<0.05.
Methods


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All junior residents beginning the trauma
rotation within study period invited to
participate.
Randomization done on a monthly alternating
schedule.
Each participant completed an anonymous
survey of previous experience.
Each line placed was monitored, with data
collected on performance and complications.
Results
Standard (n=21)
Simulated (n=13)
P value
# prior lines
7.9 (10.7)
10.6 (8.2)
0.44
Prior IJ
1.9 (2.6)
2.3 (2.6)
0.66
Prior SCV
4.9 (8.5)
4.6 (4.8)
0.91
Knowledge of
prep (1-5)
3.95 (0.92)
3.85 (0.80)
0.75
Knowledge of
equipment (1-5)
3.62 (1.02)
3.77 (0.73)
0.65
Knowledge of
technique (1-5)
3.33 (0.91)
3.46 (0.78)
0.67
Perception of
ability (1-5)
2.86 (1.12)
2.85 (1.21)
0.98
Table 1. Comparative survey (self-assessed) of subjects at study
enrollment
Results
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
A total of 39 central line attempts were
monitored in the standard group and 34 in the
simulated group.
5 attempts were internal jugular, all using ultrasound guidance. The remaining 68 lines were
placed in the subclavian vein.
Results

The simulated group had
a significantly higher
level of comfort and
ability than the standard
group, as judged by the
evaluator.
Performance Standard
rating
(n=39)
Simulated
(n=34)
P
value
Resident
comfort
(1-5)
2.93
(0.87)
3.35
(0.84)
0.03
Resident
ability
(1-5)
2.89
(0.85)
3.38
(1.04)
0.03
Average #
sticks
2.59
(1.41)
2.41
(1.86)
0.64
Table 2. Resident comfort and
ability
Results


The simulated group outperformed the standard
group on 12 of 15 variables monitored,
although this did not reach statistical
significance.
There were significantly more complications in
the standard group, including pneumothorax,
arterial puncture, and inability to complete the
procedure.
Results-Performance Measures
Standard
(n=39)
Simulated
(n=34)
P value
Improper hand wash
3/39 (7.7%)
3/34 (8.8%)
0.80
Improper prep
2/39 (5.1%)
1/34 (2.9%)
0.91
Improper drape
7/39 (17.9%)
2/34 (5.8%)
0.22
Setup incorrect
4/39 (10.3%)
3/34 (8.8%)
0.86
No trendelenburg
5/39 (12.8%)
6/34 (17.6%) 0.81
Incorrect landmark ID
1/39 (2.6%)
0/34 (0%)
0.96
Incorrect angle
9.39 (23%)
5/34 (15%)
0.55
Missed 1st attempt
27/39(69.2%) 17/34 (50%)
0.15
Average sticks
2.59 (1.41)
0.64
2.41 (1.86)
Unable to pass over wire 12/39(30.8%) 8/43 (23.5%) 0.66
Results-Complications
Standard
(n=39)
Simulated
(n=34)
P value
Arterial puncture 1/39 (2.6%)
0/34 (0%)
0.96
Need for senior
resident to take
over
12/34 (35%)
0.11
Inability to place 11/39 (28.2%)
line
5/34 (14.7%)
0.25
Pneumothorax
0/34 (0%)
0.17
3/34 (8.8%)
0.87
22/39 (56%)
4/39 (10%)
Improper
2/39 (5.1%)
position on X-ray
Results-Summary of
Performance
Standard
Performance
45/309
Errors
(19.9%)
Complications 40/195
(20.5%)
Simulated
P value
45/306 (14.7%) 0.09
20/170 (11.7%) 0.03
Line Infections


Simulated group total of
495 line days, 8 line
infections
Standard group total of
590 line days, 3 line
infections
Infection
per line
day
P value
Standard
0.005
0.05
Simulated
0.02
Conclusions
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
Simulation for central line placement using a
partial task simulator does positively impact
resident performance, particularly in regards to
line complications.
Training on the simulator prior to performance
on patients has been incorporated into training
for all junior residents rotating on the trauma
service.
Future Directions
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Establishment of proficiency standards for
training on the central line partial task simulator
necessary to ensure adequacy of training.
Continued improvements in simulators available.
Incorporation of use of ultrasound for training
on IJ placement.