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, 2009
Burden, 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
+1.4
+1.3
< 0.0001
< 0.0001
Difference
P value
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 days
Mean after, 2.3 infections per 1000 catheter days
Resource Utilization
Pre-Implementation
Post-Implementation
1-5
3-5
5 (4 manufacturers)
2 (single manufacturer)
1 per session
1 per 10 sessions
Attending Participation
Variable
Standardized
Attending Preparation
Variable
Standardized
Not standardized
Standardized
Residents Per Session
Simulators Used
CVC Kits
Facility Preparation
Estimated Program Costs
Pre-Implementation
Post-Implementation
Supply Costs
CVC Simulator
5 models ($1500)
Maintenance
4 manufacturers
CVC Kits
1 per session ($100)
$7,500
2 models ($1500)
Single manufacturer
$2600
1 per 10 sessions ($100) $260
Staff Productivity
Attending Physicians
Preparation Time
10
30 min x 26 sessions
$3,000
1
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?