Central Annals of Vascular Medicine & Research

Cite this article: Bonz J, Wong A, Evans L (2017) Implementation of a Hospital Mandated Central Venous Catheter (CVC) Training Program. Ann Vasc Med Res 4(6): 1074.

*Corresponding authorJames Bonz, Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, USA, Tel: 203-848-4746; Fax: 203-785-4580; Email:

Submitted: 22 September 2017

Accepted: 03 November 2017

Published: 08 November 2017

ISSN: 2378-9344

Copyright© 2017 Bonz et al.

OPEN ACCESS

Keywords•Central venous catheter•Medical simulation•Safety training

Perspective

Implementation of a Hospital Mandated Central Venous Catheter (CVC) Training ProgramJames Bonz*, Ambrose Wong, and Leigh EvansDepartment of Emergency Medicine, Yale School of Medicine, USA

Abstract

Background: Central venous catheters (CVC) are routinely inserted by house staff from a broad array of specialties. CVC insertion is associated with several complications. Simulation training has been shown to increase operator efficiency, success, and reduce complications. Many hospitals have a variety of CVC training programs varying in rigor and content instituted at the discretion of the departments within.

Objective: Our institution has instituted a mandated, centralized simulation training program for CVC insertion that must be completed, regardless of specialty, before house staff are allowed to insert CVCs in the clinical space. We discuss the content and administration of this course as well as assess cost and look toward future directions.

Methods: A structured, rigorous CVC training course was established at the university simulation center. All new house staff is required to complete the course and become certified.

Results: In the first year, the possible number of participants was 102; all 102 completed the training for a completion rate of 100%. Residents from 14 specialties went through the mandated CVC training course. Ten trainees failed on their first attempt at completion and required further training (10% failure rate). The total cost of administering this program was $30,938.

Conclusions: The medical simulation center operates a mandatory hospital-wide CVC training program. We believe that with mounting scholarship as its foundation, this type of mandate is necessary for improved patient care and that other institutions can gain from our experiences in implementing simulated procedural training as policy.

ABBREVIATIONSCVC: Central Venous Catheter

INTRODUCTIONOver 5 million Central Venous Catheters (CVC) are placed

annually in the United States [1]. There is significant morbidity associated with this procedure including direct injury and subsequent infection. Improvements in selective use of CVCs, placement, and maintenance have sought to reduce these complications. Although measures should be taken to address all of the facets implicated in CVC complications, an obvious point of intervention is the formal training of staff responsible for the placement of CVCs within the hospital system.

Up to 17% of catheters are estimated to result in minor catheter-related mechanical complications (arterial puncture, hematoma) and as many as 3% of CVC placements may result in a major complication (pneumothorax requiring chest tube, mediastinal hematoma, air embolus) [1,2].

Infection directly resultant from CVC placement is harder to

quantify. There are an estimated 30,000 central line associated blood stream infections (CLABSI) annually [3]. CLABSI, however, is a multifactorial problem. Reductions in CLABSI are supported by multiple interventions from the pre-procedure (practice bundles, education, instituting a culture of safety) to insertion (skin preparation, maximal barrier precautions, adherence to sterile technique, use of ultrasound, choice of dressing) to maintenance (number of times and manner in which CVC is accessed) to duration of the CVC catheter [4]. It is clear that no single intervention will eliminate CLABSI, but rather an effort on all of these fronts must be undertaken. Nonetheless, infection attributable to the insertion of the CVC can be minimized with strict adherence to sterile protocols, proper training in the use of maximal barrier precautions, and facility with ultrasound to minimize the number of skin punctures.

The cost of these complications from injury and infection on the healthcare system is considerable. The estimated extra health care cost per CLABSI is $16,500 [5]; an iatrogenic pneumothorax may cost between $17,000-$45,000 per incident [6]. Added to this is the potential medico-legal cost, which for iatrogenic pneumothorax may be as high as $143,000 per case [7].

Central

Bonz et al. (2017)Email:

Ann Vasc Med Res 4(6): 1074 (2017) 2/4

Procedural training has been shown to increase operator efficiency and reduce complications [8]. This evidence has been mounting over the last decade, and is well established for CVC insertion [9,10]. Many specialties that routinely place CVCs have instituted their own simulation training courses for their trainees. These courses vary widely in rigor and content. It is possible that within one hospital system there may be over five different “simulation courses” for training house staff, with each department potentially implementing their own; many programs do not even have a formal training program in CVC placement.

There are several mounting pressures on hospital systems to endorse a comprehensive CVC training program. Paramount is the fact that this type of training improves patient care. Moreover, the current healthcare environment is making it more and more difficult to ignore the evidence when it comes to training improvements. Through payment mechanisms, hospitals are receiving less compensation and in some instances actual penalties for potentially avoidable errors. Added to this is the scrutiny that comes with newly required public reporting of specific adverse events.

In February of 2006 Section 5001(c) of the Deficit Reduction Act of 2005 became law. This required the Secretary of the Department of Health and Human Services to identify hospital-acquired conditions (HACs) that were either costly to the system or high frequency (or both) and “could reasonably have been prevented through the application of evidence-based guidelines” [11]. Within three years a list of 10 categories of HACs were provided to The Centers for Medicare and Medicaid (CMS) and began impacting financial payment to hospitals; starting in FY2009 hospitals no longer received payment for cases in which one of the selected conditions was not present on admission. The list of HACs has been continually updated and includes several complications that are associated with CVC placement including CLABSI, iatrogenic pneumothorax, and air embolism [12].

In March of 2010 President Obama signed the Affordable Care Act (ACA) into law. Section 3008 of the ACA established the HAC Reduction Program. This provision aimed to incentivize hospitals to actively reduce the number of HACs by way of financial penalty. In FY2015 CMS was required to reduce total hospital payments by one percent for hospitals that rank in the lowest performing 25 percent with regard to HACs. That figure is set to increase to two percent by FY2017 [13].

It is important to recognize the financial impact that these legislative reforms are having on hospitals. Complications, which were once seen as part of doing business, are no longer compensated. Furthermore, hospitals may incur financial penalties and negative publicity for failure to manage these conditions. There is therefore a rising tide of unavoidable pressures on hospitals to comprehensively act: the intuitive knowledge that advanced training improves performance, supported by a body of literature specifically related to CVC training, and coupled with the financial penalties of today’s healthcare economy.

METHODSIn the winter of 2015, the Director of Procedural Simulation at

our institution met with the administration of the health system

to discuss the feasibility of a new concept: a hospital mandated CVC training program that was a prerequisite to placing a CVC within the health system, regardless of specialty. The proposal called for a standardized, rigorous course constructed specifically on previously published research on simulation-based CVC training at our institution [14]. This discussion was fostered by a desire on the part of hospital administration to address the ever-present morbidity associated with CVC placement.

The design of the simulation-based CVC training course splits the instruction into two sessions. The first session lasts approximately two hours, and the second session lasts approximately one hour. The first session requires one instructor with as many as eight trainees. The second session matches one instructor to one trainee.

Prior to engaging in the first session, learners must first watch an instructional CVC video available online (NEJM.org). The first session starts with a small group discussion reviewing informed consent, complications (with special attention paid to CLABSI and the hospital’s initiatives to address this type of hospital acquired infection), CVC relevant anatomy, ultrasound and vascular access, Seldinger technique, and post-procedure steps.

Next, the trainees undergo hands-on training with ultrasound and the vascular access models. Trainees receive instruction and practice cannulating opaque blocks with simulated vasculature (CAE Healthcare, Sarasota, FL). These ultrasound able models help the learner acquire the psychomotor skills necessary to cannulate a deep vessel using ultrasound. The skill set involves transducer placement and manipulation, recognition of vessels in soft tissue, and the ability to translate two-dimensional imaging into success in accessing deep vessels in three dimensions. Competency is demonstrated when the trainee successfully cannulates the model five times consecutively.

The first session concludes after the instructor leads an interactive demonstration of CVC placement on a task trainer from start to finish while modeling complete sterile procedure with maximal barrier precautions throughout. The instructor highlights technical nuances and common pitfalls.

The second session of the course is a one-on-one session with an instructor. Proper gowning and gloving is emphasized along with careful skin preparation and draping. The learner has the opportunity to practice the skills necessary to place the CVC, repeating all steps and is able to stop and ask questions at any point. The instructor also has the opportunity to correct technique and offer advice and solutions to commonly encountered problems. Completion of the course is achieved once learner competency can be demonstrated in a testing situation.

The testing is done against a previously published predetermined checklist [14,15] coupled with an evaluator global assessment to establish passing. If the competency evaluation is unsuccessful, the learner has the opportunity to retake their evaluation. If a trainee is unable to successfully complete the course in the allotted time, a separate session is scheduled. The entire testing encounter is captured on video from two cameras and subsequently archived.

RESULTSThe possible number of participants was 102; all 102

completed the training for a completion rate of 100%. Residents

Central

Bonz et al. (2017)Email:

Ann Vasc Med Res 4(6): 1074 (2017) 3/4

from 14 specialties went through the mandated CVC training course in its first year. A total of 11 instructors taught a total of 129 hours. Ten trainees failed on their first attempt and required further training (10% failure rate). Of those who failed their first test, two failed a subsequent test (20%). Anonymous pre and post course surveys demonstrated that trainee’s confidence level increased from 2.4 to 4.3 on a five-point Likert scale. The total cost of administering this program was $30,938 (Table 1).

DISCUSSIONBased on the mounting evidence that simulation training

reduces operator error and improves patient care, our institution has mandated the completion of a standardized CVC training program. This program requires a significant investment of faculty time and financing. The requirement of a uniform CVC training program required of all house staff hospital-wide, regardless of specialty, is rare and fairly novel.

The cost of instituting our program was $30, 938. This is less than the published cost of a similar large-scale program by Burden et al., ($36,540.20 not including salary support) [16]. Cohen et al., report a cost of $54,144 to train 68 residents over the course of a year; the significant cost differences between our program and the one reported by Cohen are attributable to a one-time ultrasound cost (not dispersed over several years) and higher facility fees [17]. Our cost includes supplies, equipment (ultrasound and task trainers), and simulation space. Importantly, this cost does not include instructor remuneration because this is considered in the umbrella of protected time for educational faculty.

As discussed previously, the cost of instituting this type of program is offset by the prevention of two episodes of CLABSI or one instance of iatrogenic pneumothorax [5,6]. It is, perhaps, an obvious progression for hospital systems to embrace the evidence for simulation training and formulate policy toward this requirement. A purely economic appraisal of this type of policy confirms its worth.

Assessment in our program is done with a combination of checklist and global rating scale. Indeed, assessment in procedural training is a hot topic in medical education. There is extensive literature supporting the use of checklists for CVC training [15,18-20], and the Accreditation Council on Graduate Medical Education (ACGME) endorses assessing procedural skills through checklists [21].

The assessment of procedural skills through checklists has come under criticism. Some authors wonder if the attention to detail necessary in a multi-point checklist comes at the expense of overall clinical aptitude [22]. Global rating scales have been used to judge overall ability (that perhaps might be missed by checklist alone) based on expert observation.

Few would argue that the goal in procedural training is to produce skilled technical operators who are safe Ma et al. observe that procedural checklists may fall short of this goal; it is possible, they note in their comparative study on the performance of checklists versus global rating scales in CVC insertion, to be technically proficient and simultaneously unsafe based on expert judgment [23]. Very few authors have combined checklists with some form of global rating scale in assessing CVC insertion [24,25].

We believe the answer to assessing procedural ability therefore requires some combination of these assessment tools. The authors feel strongly that a well-constructed checklist can identify technically skilled individuals. We also believe that these individuals do not always actively troubleshoot, adapt to unanticipated difficulties, or necessarily act in the interest of their patients. Ultimately, an expert observer must answer the question, “can this trainee complete the procedure in a manner that is reliably safe and technically sound without assistance?” We believe that a binary judgment by an expert, in addition to a minimum standard on a checklist, helps ensure the combination of technical fluidity and safe reliability that is required.

This study is limited to addressing the feasibility of instituting a comprehensive CVC training program as policy. This, of course, is its limitation: the study does not assess whether the program has reduced CVC related complications by mandating rigorous universal training. That endpoint is difficult to ascertain, as multiple interventions on various levels are being enforced simultaneously at our institution. However, this measure is not unattainable, although it will take several years to accurately judge. Rather, we contend that implementation of such a program is already justified by the existing literature. The literature demonstrates that this is the right approach to take for our patients. Certainly, there is a cost that accompanies this type of sweeping administrative decision; we believe that this cost is supported by the structure of payment, penalty, and scrutiny in our current healthcare economy.

Future studies should focus on the fine detail of cost and benefit. Additionally, we hope to train our attention to the question of skill retention, especially in those operators who place CVCs infrequently. This data could be used to inform broad questions, such as who should be trained in the first place.

Table 1: Annual Cost of CVC Course.

Item Units Cost/Unit Total Cost

Ultrasound 1 $43,953.27 $5,494/yr over 8 year period

CVC simulator 3 $4,000 $12,000 CVC simulator

replacement tissue 2 $1,749 $3,498

US cannulation training block 3 $419 $1,257

YCMS facility $1,800

CVC kits 200 $26.67 $5,334

Sterile gloves 200 $0.50 $100

Sterile gowns 150 $2.50 $375

Sterile US covers 150 $7 $1,050

Masks 150 $16

Bonnets 150 $14 Total Program Costs/

yr $30,938

Central

Bonz et al. (2017)Email:

Ann Vasc Med Res 4(6): 1074 (2017) 4/4

Bonz J, Wong A, Evans L (2017) Implementation of a Hospital Mandated Central Venous Catheter (CVC) Training Program. Ann Vasc Med Res 4(6): 1074.

Cite this article

CONCLUSIONSOur institution is in its second year of operating a mandatory

hospital-wide CVC training program and will continue training all new house staff and fellows in this important procedure. We believe that with mounting scholarship as its foundation, this type of mandate is necessary for improved patient care and that other institutions can gain from our experiences in implementing simulated procedural training as policy.

REFERENCES1. McGee DC, Gould MK. Preventing complications of central venous

catheterization. N Engl J Med. 2003; 348: 1123-33.

2. Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001; 286: 700-7.

3. CDC National and State Healthcare-Associated Infections Progress report. 2014.

4. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis. 2011; 52: 162-193.

5. Liang SY, Marschall J. Update on emerging infections: news from the Centers for Disease Control and Prevention. Vital signs: central line-associated blood stream infections--United States, 2001, 2008, and 2009. Ann Emerg Med. 2011; 58: 447-451.

6. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003; 290: 1868-1874.

7. Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and liability related to central vascular catheters: a closed claims analysis. Anesthesiology. 2004; 100: 1411-1418.

8. Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Ann Intern Med. 2013; 158: 426-432.

9. Ma IW, Brindle ME, Ronksley PE, Lorenzetti DL, Sauve RS, Ghali WA. Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis. Acad Med. 2011; 86: 1137-1147.

10. Madenci AL, Solis CV, de Moya MA. Central venous access by trainees: a systematic review and meta-analysis of the use of simulation to improve success rate on patients. Simul Healthc. 2014; 9: 7-14.

11. CMS.https://www.cms.gov/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Statute_Regulations_Program_Instructions.html. 2016.

12. CMS.https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html. 2016.

13. Kahn CN 3rd, Ault T, Potetz L, Walke T, Chambers JH, Burch S. Assessing Medicare’s hospital pay-for-performance programs and whether they are achieving their goals. Health Aff (Millwood). 2015; 34: 1281-1288.

14. Evans LV, Dodge KL, Shah TD, Kaplan LJ, Siegel MD, Moore CL, et al. Simulation training in central venous catheter insertion: improved performance in clinical practice. Acad Med. 2010; 85: 1462-1469.

15. Evans LV, Dodge KL. Simulation and patient safety: evaluative checklists for central venous catheter insertion. Qual Saf Health Care. 2010; 19: 42-46.

16. Burden AR, Torjman MC, Dy GE, Jaffe JD, Littman JJ, Nawar F, et al. Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle? J Clin Anesth. 2012; 24: 555-560.

17. Cohen ER, Feinglass J, Barsuk JH, Barnard C, O’Donnell A, McGaghie WC, et al. Cost savings from reduced catheter-related bloodstream infection after simulation-based education for residents in a medical intensive care unit. Simul Healthc. 2010; 5: 98-102.

18. Barsuk JH, Ahya SN, Cohen ER, McGaghie WC, Wayne DB. Mastery learning of temporary hemodialysis catheter insertion by nephrology fellows using simulation technology and deliberate practice. Am J Kidney Dis. 2009; 54: 70-76.

19. Dong Y, Suri HS, Cook DA, Kashani KB, Mullon JJ, Enders FT, et al. Simulation-based objective assessment discerns clinical proficiency in central line placement: a construct validation. Chest. 2010; 137: 1050-1056.

20. Velmahos GC, Toutouzas KG, Sillin LF, Chan L, Clark RE, Theodorou D, et al. Cognitive task analysis for teaching technical skills in an inanimate surgical skills laboratory. Am J Surg. 2004; 187: 114-119.

21. ACGME. Toolbox of assessment methods. 2000; V1.1.

22. Cunnington JP, Neville AJ, Norman GR. The risks of thoroughness: Reliability and validity of global ratings and checklists in an OSCE. Adv Health Sci Educ Theory Pract. 1996; 1: 227-233.

23. Ma IW, Zalunardo N, Pachev G, Beran T, Brown M, Hatala R, et al. Comparing the use of global rating scale with checklists for the assessment of central venous catheterization skills using simulation. Adv Health Sci Educ Theory Pract. 2012; 17: 457-470.

24. Millington SJ, Wong RY, Kassen BO, Roberts JM, Ma IW. Improving internal medicine residents’ performance, knowledge, and confidence in central venous catheterization using simulators. J Hosp Med. 2009; 4: 410-416.

25. Woo MY, Frank J, Lee AC, Thompson C, Cardinal P, Yeung M, et al. Effectiveness of a novel training program for emergency medicine residents in ultrasound-guided insertion of central venous catheters. CJEM. 2009; 11: 343-348.