Placement of Central Venous Line Using Simulation: A Resident-to-Resident Teaching Model
Hormoz Kianfar, M.D., Avinesh Bhar, M.D., Amreen Dinani, M.D., George Benedetto, Melvin Hochman, M.D., Jason Gluck, M.D.
New York Hospital Medical Center of Queens
Introduction: An estimated 5 million central venous line (CVL) placements are performed every year in the US. In teaching hospitals, residents place most CVLs. Each individual residency program is responsible for ensuring resident proficiency at CVL insertion while maintaining patient safety; however, as work hours are being reduced and programs increase in size, ensuring proficiency is challenging. The traditional approach of “see one, do one, teach one” is being supplanted by a more intensive, multi-pronged approach involving didactics, the internet and the use of simulators. Current data has been favorable to the adoption of simulators in CVL placement training, but none have evaluated a resident-to-resident teaching model.
Purpose: To determine if senior residents, using a standardized protocol, can effectively train junior residents in ultrasound-guided CVL placement.
Method: 22 PGY-2 residents were enrolled in a standardized ultrasound guided CVL placement workshop conducted by a PGY-3 and observed by an attending from behind a one-way mirror. Each group of 3-5 residents were required to read selected educational material and watch an instructional video on CVL placement [NEJM – Clinical Medicine Video] prior to attending a 2-hour workshop. The didactic session included a review of indications, technique and complications of ultrasound guided CVL placement and a live demonstration on CentraLineMan (Simulab Corp, Seattle, WA). Each participant then placed at least one CVL on CentralLineMan under the supervision of the senior. Remediation was provided as necessary. Participants completed a questionnaire, based on a 1-5 point Likert scale, to assess their CVL comfort level prior to the workshop and again at 3 months.
Results: 19 PGY-2 residents attended the workshops, 3 did not participate due to scheduling conflicts. The residents rated the course on as very educational (mean 4.3), helpful (mean 4.5) and realistic (mean 4.3). The workshop had met or exceeded their expectations, with a mean score of 4.4. At 3-month follow-up, the average number of CVLs placed by each resident had increased from 1.5 to 3.8 and with a concomitant increase in comfort from a mean of 2.3 to 4.
Conclusion: Central line simulation supervised by senior residents is a novel training method. Residents found the course highly educational, realistic, and effective. After this workshop, they actively placed CVLs and were more comfortable. We demonstrated that, using a standardized protocol and simulation technique, senior residents can effectively train junior residents in ultrasound guided CVL placement.