1. Do More With Less: A Surgery Directed Institutional Model for Resident Central Line Training David Leshikar, M.D. Jonathan Pierce, M.D. Edgardo Salcedo, M.D. Gurpreet Bola, B.S. Joseph Galante, M.D. April 23, 2013

2. “See One, Do One, Teach One” Apprenticeship model Little to no supervision Bedside teaching

3. Simulation Training Background Uses Procedural training CPR/ACLS Endoscopy Laparoscopy Endovascular Fundamentals of Laparoscopic Surgery

4. Central Venous Catheters (CVC) Common bedside procedure Performed by many specialties Complications

5. Central Line Simulation CVC Simulation: Decreases complications Improves comfort level Widespread adoption Barsuk, et al, Crit Care Med, 2009. Barsuk, et al, Arch Intern Med, 2009 Burden, et al, J Clin Anesth, 2012.

6. Procedural Simulation Expensive Equipment costs Faculty time No standardized assessment metrics Redundant within institutions Duncan, et al, J Grad Med Educ, 2010

7. Hypothesis A curriculum centralized in the department of surgery Single faculty trainer Maintain quality of training Institution wide Efficient resource utilization

8. Curriculum Web-based module Covered all aspects of central line placement Pre/Post testing Hands-on simulation training Technical training – all components Video assessment

9. Resource Utilization Equipment costs CVC simulator Simulator supplies Staff productivity Number of faculty involved Preparation time Compared pre vs post implementation

10. Pre-Implementation Individual departments Inconsistent simulator use No standardization

11. Post-Implementation Study Period: July 2010-June 2012 Departments involved: Surgery Internal Medicine Emergency Medicine Family Practice Pediatrics Anesthesia Standardized evaluation Single faculty trainer

12. Online Module July 2010 – June 2011July 2011 – June 2012 N= 132N = 126 Pre-Test Mean 7.07.1 Post-Test Mean 8.4 Difference +1.4+1.3 P value < 0.0001

13. Video Assessments PGY-1PGY-2PGY-3PGY-4+ N=26N=9N=5N=1 Pre-Test Mean14.215.012.815.0 Post-Test Mean17.515.414.817.0 Difference+3.3+0.4+2.0 P value0.00010.4260.0217

14. Central Line Infections Mean before, 3.8 infections per 1000 catheter days Mean after, 2.3 infections per 1000 catheter days

15. Resource Utilization Pre-ImplementationPost-Implementation Residents Per Session1-53-5 Simulators Used5 (4 manufacturers)2 (single manufacturer) CVC Kits1 per session1 per 10 sessions Attending ParticipationVariableStandardized Attending PreparationVariableStandardized Facility PreparationNot standardizedStandardized

16. Estimated Program Costs Pre-ImplementationPost-Implementation Supply Costs CVC Simulator 5 models ($1500)$7,500 2 models ($1500)$3,000 Maintenance 4 manufacturers Single manufacturer CVC Kits 1 per session ($100)$2600 1 per 10 sessions ($100)$260 Staff Productivity Attending Physicians 10 1 Preparation Time 30 min x 26 sessions 13 hours None Sim Lab Staff Setup 4 manufacturers Single manufacturer Faculty Familiarity 10 different attendings Single attending

17. Summary Streamlined development Effective instruction Improved efficiency

18. Conclusion Standardization of simulation Maintained quality of teaching Decrease resource utilization

19. Questions?