Nosocomial Infections Clinical Trial
Official title:
Emergency Medicine Residents Performance in Maximum Barrier Precautions During Central Venous Catheter Placement: Effect of Stimulation-based Training
1. Baseline performance in maximal barrier precaution technique of Emergency Medicine (EM)
residents, certified in CVC placement, is poor
2. Simulation-based training in maximal barrier precaution technique during central venous
catheter (CVC) placement will improve baseline performance of EM residents
Central line associated bloodstream infection (CL-ABI) is an important and preventable cause
of nosocomial infections and is responsible for considerable morbidity and mortality. It is
estimated that 5 to 26% of patients experience an infectious complication from their central
venous catheter [1]. In the United States, it is estimated that nearly 50,000 patients
develop central line associated bloodstream infections in the ICUs annually, at a rate of
approximately 5 infections per 1000 catheter days [2] and as many as 15,000 deaths annually.
Central line associated bloodstream infections are also associated with increased hospital
and ICU lengths of stay in the ICU (2). Estimates of the cost of CL-ABI to hospitals range
from $25,000 to $65,000 per patient [3, 4].
The Centers for Disease Control have published guidelines for the prevention of CL-ABI that
represent a collaborative effort by a multidisciplinary coalition of professional
organizations that provide evidence based recommendations to prevent catheter related
infections [5]. The interventions emphasize five distinct practices, including: education
and training of healthcare providers who place and care for catheters, utilizing maximum
sterile barrier precautions during catheter placement, skin preparation using 2%
chlorhexidine, avoiding routine replacement of central lines as a strategy to reduce
infection, and using antiseptic or antibiotic coated lines in the event that infection rates
remain high despite adherence to the above measures [5].
Several studies have demonstrated impressive reductions in CL-ABI from the application of
these strategies, ranging from 18 to 100% reductions and realizing significant reductions in
mortality and cost [2]. The simple introduction of maximum sterile barrier precautions to
insert central lines has been observed to dramatically reduce infection rates for over a
decade [6]. However, the CDC's guidelines, despite their seeming simplicity, have been found
to be frequently insufficiently applied, whether by ignorance or omission [2].
In the past 12 months there have been a total 24 documented central venous line (CVL)
infections at SLRHC with cumulative rate of infection of 3.8 per 1000 central line days.
These infection rate figures are above the benchmark experience. For SLRHC the cost incurred
over the past 12 months is estimated to be $1,080,000.
Training and education of healthcare personnel and the utilization of maximum sterile
precautions are two important areas. Residents still most frequently learn central line
placement techniques by the "see one, do one, teach one" method, which by its very
definition allows for a multitude of techniques in practice. While this teaching
theoretically includes the utilization of maximal sterile precautions for central line
placement, the focus of teaching, and of residents' anxieties, is most often focused on the
proper placement of the line, not the sterile technique used to place it. In emergency
medicine, residents also frequently learn procedures in an emergent environment- where
attention to maximum sterile precautions may be less than ideal. Guzzo et al found in
particular that mentors of trainees performing CVC placements in both emergent and
non-emergent situations were significantly less likely to consistently utilize maximum
sterile precautions [8]. Furthermore, in a study of a video-based training on sterile
technique in CVC insertion in a trauma resuscitation unit that evaluated only non-emergent
CVC placements, a total of 5 cases of central- catheter- related bacteremia were reported on
just 68 patients, and even with video based training, 26% of residents continued to have
infractions in their compliance with sterile precautions [9].
Medical simulators allow residents to practice skills in a realistic and interactive
environment that minimizes risk to patients. Studies have found simulation to be an
effective means for teaching skills as diverse as ACLS and airway management to laparoscopic
surgical skills [10,11,12]. Additionally, the use of audio-visual equipment in a medical
simulator to record a resident's performance gives valuable firsthand feedback that is
otherwise not available, as it allows residents to visualize their own missteps [13]. This
is hypothesized to be of particular value in the proper acquisition of physical skills such
as maximum sterile precautions. Furthermore, the Society for Academic Medicine has recently
published a consensus paper outlining a research agenda for the use of simulation in
Emergency Medicine that identifies procedural training as a priority area and notes that it
is "an incompletely tested assessment method for the range of procedural skills required of
emergency physicians [14]." The paper goes on to state that:
"Competency" must be defined precisely for every procedure. Each step must be identified,
and the proper sequence of those steps must be established. Objective checklists and expert
scoring systems must be created, and training and assessment methodologies must be
validated. [14] With this in mind, the Department of Emergency Medicine has recently
approved a training policy in aseptic technique during central venous access placement (see
attached copy). All EM residents will be trained in MBP techniques in the Sim Lab. Training
will include baseline assessment of residents skills in maintaining maximum sterile
precautions using a standardized scoring tool, videotape training, short exam, and
individual simulated debriefing on performance of correct MBP with follow up assessment and
training as needed.
We plan to collect data prospectively on all EM residents who will undergo evaluation and
training in maximum barrier precaution during CVC placement. Data will be reviewed and
analyzed for future research publication
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