Making Procedures Safe(r)
Central Line Insertion
Paul Currier, MD, MPH
MGH Pulmonary & Critical Care Unit
Associate Program Director for Procedures and Critical Care Education, DOM
Instructor in Medicine, Harvard Medical School
Financial Disclosures: None
Central Venous Access
Complications
Puncture of Artery
Collapsed Lung
Air in Vessel
Abnormal Heart Rhythm
Infection
Blood Clot
Death
Safety Interventions……
Policy
Education
Procedure Modifications –
structural and forcing functions
Proven Policy Interventions
Hand Washing
Full Barrier Precautions
Chlorhexidine
Avoiding Femoral Site
Removing Unnecessary Catheters
How to Teach Procedures?
1. Classic Mentoring: Watch Someone, try it
on a patient
2. Instructional Videos
3. Simulation
4. Animal Models
Mentoring Model
Dependent on Individual Variation
Dependent on Clinical Opportunity
High Risk Learning
Impact of Videos on Procedural
Training
• 210 Medical Residents
• NEJM Videos on Arterial Catheter &
Central Line Placement
• Pre-test, procedure, post-test
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
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)
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
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
Emotionality of the Experience is the Difference
Circumplex Model of Emotion: Russell and Feldman Barrett, 1999
Central Venous Catheter Insertion
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
No confidence
7
8
9
Extremely confident
Rate your confidence in being able to place a central line after this session?
1
2
3
4
5
6
No confidence
7
8
9
Extremely confident
Rate the ability of this training session to teach central line placement:
1
Poor
2
3
4
5
6
7
8.1
9
Excellent
Rate the realism of this simulation:
1
Not realistic
2
3
4
5
6
7.2
8
Extremely Realistic
9
Resident Commentary
“Great program! All interns
should do this before the
MICU, even after a few
lines”
“Small group training was
perfect!”
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
Suturing