Simulation-based training for emergency medicine residents in sterile technique during central venous catheterization: impact on performance, policy, and outcomes.

OBJECTIVES: Central line-associated bloodstream infection (CLABSI) is a preventable nosocomial infection. Simulation-based training in sterile technique during central venous catheter (CVC) placement for emergency medicine (EM) residents, and its effect on changing the medical intensive care unit (MICU) practice of routine replacement of CVCs placed under sterile technique in the emergency department (ED), has not been evaluated. METHODS: Emergency medicine residents received simulation-based sterile technique training during CVC placement between May 2008 and September 2010. Between June 2008 and January 2011, the authors reviewed records of patients who had CVCs placed in the ED under sterile technique by EM residents and were admitted to the MICU (group 1) and CVCs placed in the MICU under sterile technique by internal medicine (IM) residents (group 2). IM residents completed similar simulation-based training before May 2008. Changes in EM residents' sterile technique performance scores were compared, as well as CLABSI rates in both groups. EM residents' CVC procedural skills were not assessed. RESULTS: Seventy-six EM residents completed simulation-based training with significant improvement in performance (median scores 13 out of 24 before training, 24 out of 24 after training; p < 0.001). CLABSI rates per 1,000 catheter-days were 1.02 in group 1 and 1.02 in group 2 (p = 0.99). Both groups had similar demographics, acuity, and mortality (p > 0.5). CONCLUSIONS: Routine replacement of CVCs placed in the ED under sterile technique after simulation-based training would appear to be unnecessary. These findings demonstrate patient-centered outcomes that are comparable for CVCs in ED-admitted MICU patients, regardless of whether the CVC was placed in the ED or MICU.

Simulation-based training for nurses in sterile techniques during central vein catheterization.

BACKGROUND: The effectiveness of simulation-based training of critical care nurses in sterile techniques has not been determined. OBJECTIVE: To evaluate the effectiveness of simulation-based training of critical care nurses to use sterile techniques during central vein catheterization and the effect of such training on infection rates. METHODS: A prospective controlled study with 12-month observational follow-up to assess the rate of catheter-related bloodstream infections in a 23-bed medical, surgical, neurological critical care unit. RESULTS: Forty-six critical care nurses completed assessment and training in sterile technique skills in the simulation laboratory. Performance scores at baseline were poor: median scores in each category ranging from 0 to 2 out of a maximum score of 4 and a median total score of 7 out of a maximum score of 24. After simulation-based training, nurses' median scores in each ST category and their total scores improved significantly, with the median total score increasing to 23 (P < .01; median difference, 15; 95% CI, 14-16). After completion of the simulation-based training intervention, the mean infection rate in the unit was reduced by 85% from 2.61 to 0.4 infections per 1000 catheter-days (P = .02). The incidence rate-ratio derived from the Poisson regression (0.15; 95% CI, 0.03-0.78) indicates an 85% reduction in the incidence of catheter-related bloodstream infections in the unit after the intervention. CONCLUSION: Simulation-based training of critical care nurses in sterile technique is an important component in the strategy to reduce the occurrence of such infections and promote patient safety.

Nurse-driven, protocol-directed weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians.

PURPOSE: Ventilator weaning protocols can improve clinical outcomes, but their impact may vary depending on intensive care unit (ICU) structure, staffing, and acceptability by ICU physicians. This study was undertaken to examine their relationship. DESIGN/METHODS: We prospectively examined outcomes of 102 mechanically ventilated patients for more than 24 hours and weaned using nurse-driven protocol-directed approach (nurse-driven group) in an intensivist-led ICU with low respiratory therapist staffing and compared them with a historic control of 100 patients who received conventional physician-driven weaning (physician-driven group). We administered a survey to assess ICU physicians' attitude. RESULTS: Median durations of mechanical ventilation (MV) in the nurse-driven and physician-driven groups were 2 and 4 days, respectively (P = .001). Median durations of ICU length of stay (LOS) in the nurse-driven and physician-driven groups were 5 and 7 days, respectively (P = .01). Time of extubation was 2 hours and 13 minutes earlier in the nurse-driven group (P < .001). There was no difference in hospital LOS, hospital mortality, rates of ventilator-associated pneumonia, or reintubation rates between the 2 groups. We identified 4 independent predictors of weaning duration: nurse-driven weaning, Acute Physiology and Chronic Health Evaluation II score, vasoactive medications use, and blood transfusion. Intensive care unit physicians viewed this protocol implementation positively (mean scores, 1.59-1.87 on a 5-point Likert scale). CONCLUSIONS: A protocol for liberation from MV driven by ICU nurses decreased the duration of MV and ICU LOS in mechanically ventilated patients for more than 24 hours without adverse effects and was well accepted by ICU physicians.

Performance of medical residents in sterile techniques during central vein catheterization: randomized trial of efficacy of simulation-based training.

BACKGROUND: Catheter-related bloodstream infection (CRBSI) is a preventable cause of a potentially lethal ICU infection. The optimal method to teach health-care providers correct sterile techniques during central vein catheterization (CVC) remains unclear. METHODS: We randomly assigned second- and third-year internal medicine residents trained by a traditional apprenticeship model to simulation-based plus video training or video training alone from December 2007 to January 2008, with a follow-up period to examine CRBSI ending in July 2009. During the follow-up period, a simulation-based training program in sterile techniques during CVC was implemented in the medical ICU (MICU). A surgical ICU (SICU) where no residents received study interventions was used for comparison. The primary outcome measures were median residents' scores in sterile techniques and rates of CRBSI per 1,000 catheter-days. RESULTS: Of the 47 enrolled residents, 24 were randomly assigned to the simulation-based plus video training group and 23 to the video training group. Median baseline scores in both groups were equally poor: 12.5 to 13 (52%-54%) out of maximum score of 24 (P = .95; median difference, 0; 95% CI, 0.2-2.0). After training, median score was significantly higher for the simulation-based plus video training group: 22 (92%) vs 18 (75%) for the video training group (P < .001; median difference, 4; 95% CI, 3-6). During the follow-up period, there was a significantly lower rate of CRBSI in the MICU (1.0 per 1,000 catheter-days) compared with the SICU (3.4 per 1,000 catheter-days) (P = .03). The incidence rate ratio derived from the Poisson regression (0.30; 95% CI, 0.10-0.91) indicated there was a 70% reduction in the incidence of CRBSI in the postintervention MICU compared with the preintervention MICU and the postintervention SICU. CONCLUSIONS: Simulation-based training in sterile techniques during CVC is superior to traditional training or video training alone and is associated with decreased rate of CRBSI. Simulation-based training in CVC should be routinely used to reduce iatrogenic risk. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00612131; URL: clinicaltrials.gov.