Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
Department of Pediatric Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
Medicine (Baltimore). 2024 Jun 7;103(23):e38346. doi: 10.1097/MD.0000000000038346.
Central venous catheter (CVC) placement is a challenging procedure with known iatrogenic risks. However, there are no residency program requirements to demonstrate baseline CVC procedural competency. Competency-based procedural education has been shown to decrease CVC-associated morbidity, but there has been limited literature about institution-wide efforts to ensure initial trainee competency for CVC placement. This study describes the implementation of a competency-based CVC curriculum for first-year interns across an institution before supervised clinical care. An institution-wide, simulation-based mastery training curriculum was designed to assess initial competency in CVC placement in first-year residents during 2021 and 2022. A checklist was internally developed with a multidisciplinary team. Using the Mastery-Angoff technique, minimum passing standards were derived to define competency levels considered appropriate for intern participation in supervised clinical care. Interns were trained through the competency-based program with faculty assessing intern performance using the CVC checklist to verify procedural competency. Over 2 academic cycles, 229 interns from 20 specialties/subspecialties participated. Overall, 83% of interns met performance standards on their first posttest attempt, 14% on the second attempt, and 3% on the third attempt. Interns from both cycles demonstrated significant improvement from baseline to posttest scores (P < .001). Overall, 10.5% of interns performed dangerous actions during assessment (malpositioning, retained guidewire, or carotid dilation). All interns ultimately achieved the passing standard to demonstrate initial competency in the simulation assessment. All participating interns demonstrated simulation-based competency allowing them to place CVCs under supervised clinical care. Dangerous actions, however, were not uncommon. Simulation-based teaching and learning frameworks were a feasible method to promote patient safety through an institutional-wide verification of preliminary procedural competency.
中心静脉导管 (CVC) 置管是一项具有已知医源性风险的挑战性操作。然而，住院医师规范化培训项目并无要求展示基本的 CVC 操作能力。基于能力的操作教育已被证明可降低与 CVC 相关的发病率，但关于确保 CVC 置管初始培训生能力的机构范围的努力，文献有限。本研究描述了在开始临床监督护理之前，在一个机构中为第一年住院医师实施基于能力的 CVC 课程的情况。设计了一个机构范围内的、基于模拟的精通培训课程，以评估第一年住院医师在 2021 年和 2022 年期间进行 CVC 置管的初始能力。使用多学科团队内部开发了一份清单。使用精通-安戈夫技术，得出了最低通过标准，以定义认为适合住院医师参与监督临床护理的能力水平。住院医师通过基于能力的课程接受培训，教师使用 CVC 清单评估住院医师的表现，以验证操作能力。在两个学术周期中，来自 20 个专业/亚专业的 229 名住院医师参加了该课程。总体而言，83%的住院医师在第一次尝试后通过了考试标准，14%在第二次尝试后通过，3%在第三次尝试后通过。来自两个周期的住院医师在基线和后测分数之间均表现出显著提高（P<0.001）。总体而言，10.5%的住院医师在评估期间进行了危险操作（位置不当、留置导丝或颈动脉扩张）。所有住院医师最终都达到了通过标准，证明了在模拟评估中具备初步能力。所有参与的住院医师都展示了基于模拟的能力，允许他们在监督临床护理下进行 CVC 置管。然而，危险行为并不少见。基于模拟的教学和学习框架是通过机构范围验证初步程序能力来促进患者安全的可行方法。
