Omar is a second year resident asked to place an ultrasound guided central line on a patient. He has always wanted to perform this procedure but struggles with finding the right hand positioning and can’t thread the wire, forcing his senior resident to take over. Omar feels that he is performing the procedure awkwardly but is unsure of what corrections he needs to make. He wonders if there is a better way to learn the movements necessary to perform an ultrasound guided central line.
Emergency physicians are frequently asked to obtain ultrasound guided central venous access. However, it can be difficult to learn and perfect the required muscle movements. This Feature Educational Innovation (FEI), titled “Using Hand Motion Analysis to Establish Learning Curves in Ultrasound Guided Central Venous Access” was originally posted by the CAEP EWG FEI Team on April 11, 2016 and answers the question: “How can we prepare residents to learn ultrasound guided central line?” A PDF version is available here. A CAEP Cast is available here.
Description of the Innovation
The goals of this project were to develop a competency-based curriculum to teach junior residents the skills of ultrasound guided (USG) central venous catheter (CVC) insertion on a simulator, and to study the volume and type of practice that leads to proficiency in these skills.
Central venous catheter (CVC) insertion is a key procedural competency for residents in Emergency Medicine under the Medical Expert Role in the CanMEDS Physician Competency Framework. However, there is little evidence to inform the type and volume of practice that leads to proficiency in this skill.
The authors used an iterative process for curriculum design starting with input from local experts to develop and implement the curriculum over the summers of 2014 and 2015. The curriculum was modified by instructor input to increase the volume of practice and to include specific drills for the more challenging parts of the procedure. The authors found that residents require considerable practice of the skills of simultaneous probe manipulation, needle manipulation and image interpretation.
In the current iteration of the curriculum, residents learn both the femoral and internal jugular approach to USG CVC insertion. They practice the ultrasound dependent portion of the procedure approximately 85 times over the course of 3 training sessions. Hand motion analysis, which captures discreet movements of the hand and has been shown to be a valid measure of expertise in these skills. Each training session involved performing a baseline hand motion analysis. Eight PGY2 residents, 4 from Emergency Medicine and 4 from Anesthesiology participated in the curriculum during the summer of 2015.
Over the course of training, all 8 of the residents showed steady improvement. The residents approached or exceeded the expert benchmarks for ‘time for procedure’, ‘needle-hand motion count’ and ‘probe-hand motion count’ by the third training session and after practicing the US dependent portion of the procedure approximately 85 times. The time commitment and volume of practice is considerable, but is consistent with similar studies in the clinical setting.
A compelling argument can be made that there is an ethical imperative for residents to practice procedural skills as much as possible in the simulation lab prior to attempts on real patients. In learning ultrasound-guided percutaneous procedures, residents tend to display a predictable pattern of errors. These include poor needle tip visualization, awkward probe manipulation and awkward needle manipulation. Overcoming these specific errors of technique requires considerable focused and deliberate practice along with expert feedback.
This approach to learning is difficult in the clinical setting where opportunities for practice are inconsistent and residents are unable to pause mid procedure to practice specific elements. Therefore, in keeping with contemporary learning theory the novice resident will benefit from high volume deliberate practice of this procedure in the simulation lab. Furthermore, the patient will benefit from avoiding the predictable pattern of errors made by novices.
What resources does your simulation lab have to prepare its learners to perform ultrasound guided central lines?
More about CAEP FEI
This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.
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