Use of a Mastery Learning Model to Improve Internal Medicine Resident Skills in Central Venous Catheter Insertion: Results of a Pilot Study

Background:

Central venous catheter (CVC) insertions are frequently performed by internal medicine residents. Research shows that complications including pneumothorax and arterial puncture diminish when operators require fewer needle passes and use ultrasound. We demonstrated previously that a simulation‐based mastery learning model improved thoracentesis and advanced cardiac life support (ACLS) skills and associated clinical care. In this study we evaluated the effect of simulation‐based training in CVC insertion on resident skill, self‐reported confidence, and number of needle passes required during actual medical intensive care unit (MICU) procedures.

Methods:

This was a cohort study of internal jugular (IJ) and subclavian (SC) CVC insertion by 41 internal medicine residents rotating in the Northwestern Memorial Hospital MICU over a 5‐month period. Using a checklist, 28 residents underwent baseline skill assessment in IJ and SC CVC insertion using Simulab's CentralLineMan® simulator prior to rotating through the MICU. The residents then received two 2‐hour education sessions featuring a lecture, training with ultrasound, deliberate practice with the CVC simulator, and feedback. They were retested and considered trained to mastery if they met or exceeded a minimum passing score (MPS) set by an expert panel. A comparison group was identified from 13 residents who rotated through the MICU 6 weeks before the trained residents. CVCs inserted during the study period were identified, and residents were surveyed on the number of needle passes, complications, and procedural self‐confidence using a 100‐point scale (from 0 = not confident to 100 = very confident). Results from the simulation‐trained residents were compared with those from the untrained residents.

Results:

No resident met the MPS (79.1%) for CVC insertion at baseline: M = 48.4%, SD = 23.1% for IJ; M = 45.2%, SD = 26.3% for SC. All residents met or exceeded the MPS at posttest: M = 94.8%, SD = 10.0% for IJ; M = 91.1%, SD = 17.8% for SC (P < .005). In the MICU, trained residents required significantly fewer needle passes to insert a CVC than did untrained residents: 1.76, SD = 1.0, vs. 3.3, SD = 3.21 (P = .04). Trained residents displayed more self‐confidence about procedural skills (M = 83, SD = 12, vs. M = 71, SD = 19 (P < .01). The groups did not differ in pneumothorax or arterial puncture rates.

Conclusions:

A simulation‐based mastery learning program increased residents' skills in IJ and SC CVC insertion, decreased the number of needle passes, and improved resident confidence when performing actual procedures. Further study is needed to assess improvement in such other clinical outcomes as reduced catheter infections after simulation‐based training.

Author Disclosure:

J. H. Barsuk, none; W. C. McGaghie, none; E. R. Cohen, none; J. Balachandran none; D. B. Wayne, none.