Practice Makes (Almost) Perfect: Reducing Catheter-related Bacteremia Using Simulation-based Training
Practice Makes (Almost) Perfect: Reducing Catheter-related Bacteremia Using Simulation-based Training
Abstract & Commentary
By Robert Muder, MD, Hospital Epidemiologist, Pittsburgh VA Medical Center, Section Editor, Hospital Epidemiology, is Associate Editor for Infectious Disease Alert.
Dr. Muder does research for Aventis and Pharmacia.
Source: Barsuk JH et al. Use of simulation based education to reduce catheter-related bloodstream infections. Arch Intern Med. 2009;169:1420-1423.
In order to reduce the rate of catheter-related bloodstream infections (CRBSIs) in intensive care units, Northwestern Memorial Hospital implemented patient care bundles in all ICUs in August 2005. The bundles included use of hand hygiene, full body drapes, use of chlorhexidine as a skin disinfectant, and sterile technique by the operator. Resident physicians performed 98% of catheter insertions; all residents were given didactic training in correct insertion procedures.
Beginning in December 2006, internal medicine and emergency medicine residents, who provided care in the medical ICU, underwent simulation-based training in central-venous catheter insertion prior to their ICU rotations. In addition to lectures on indications, insertion techniques and complications, residents received a step-by-step demonstration of catheter insertion techniques emphasizing evidenced-based guidelines for reducing CRBSIs embodied in the patient care bundle. Following this, they received three hours of training using an ultrasound device and patient simulator. Residents were required to achieve a minimum passing score; those that did not performed an extra hour of practice. All ultimately passed. During this period, surgical residents continued to receive the original didactic training but did not receive simulation-based education.
Barsuk et al compared CRBSI rates for the pre- and post-simulation-based education periods, and compared the rates in the MICU and SICU. The rate of CRBSIs in the MICU was 3.20/1,000 catheter-related days in the pre-intervention period, compared with 0.50/1,000 patient days in the post-intervention period. In the SICU, the rate was 4.86/1,000 patient days in the first period and 5.26/1,000 patient days in the second period.
Commentary
There are approximately 80,000 CRBSIs in the United States annually, with an attributable mortality of up to 25%. Both conscientious adherence to sterile technique at the time of insertion and use of antimicrobial-impregnated devices may reduce the risk of CRBSIs. The study by Barsuk et al demonstrates convincingly that a program of simulation-based education in catheter insertion for physicians in training has a dramatic effect in reducing infection rates. Although the study was not randomized, and used a partial pseudo-experimental ("before and after") design, the degree in the infection rate, 85%, is truly striking. It's also notable that the CRBSI rate in the surgical ICU, in which the training was not offered, did not decline, and actually showed a small increase. As there were no other initiatives in place to decrease CRBSIs, and the patient illness scores appeared not to have changed over time, one must conclude that the education was effective.
What is not clear from the report is what aspects of the education were essential. It might have been the increased emphasis on sterile technique or the increased skill at insertion gained by the trainees. The latter could lead to quicker insertion times, fewer needle sticks with attendant tissue trauma, and increased facility with maintaining a sterile field. Regardless, the benefits of the educational program are clear. Thirty years ago (yes it's really been that long!), when I was a resident in a busy ICU, I learned how to place a catheter under the old "see one, do one, teach one" system, which undoubtedly was an effective means to propagate all of the faulty techniques learned by more senior residents. Given the current, appropriate attention to patient safety, the alternative approach described by Barsuk et al is welcome.
In order to reduce the rate of catheter-related bloodstream infections (CRBSIs) in intensive care units, Northwestern Memorial Hospital implemented patient care bundles in all ICUs in August 2005.Subscribe Now for Access
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