Creating and evaluating a data-driven curriculum for central venous catheter placement

Abstract

Background: Central venous catheter placement is a common procedure with a high incidence of error. Other fields requiring high reliability have used Failure Mode and Effects Analysis (FMEA) to prioritize quality and safety improvement efforts.

Objective: To use FMEA in the development of a formal, standardized curriculum for central venous catheter training.

Methods: We surveyed interns regarding their prior experience with central venous catheter placement. A multidisciplinary team used FMEA to identify high-priority failure modes and to develop online and hands-on training modules to decrease the frequency, diminish the severity, and improve the early detection of these failure modes. We required new interns to complete the modules and tracked their progress using multiple assessments.

Results: Survey results showed new interns had little prior experience with central venous catheter placement. Using FMEA, we created a curriculum that focused on planning and execution skills and identified 3 priority topics: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) improved needle access, which prompted the development of an ultrasound training module; and (3) catheter-associated bloodstream infections, which were addressed through training on maximum sterile barriers. Each module included assessments that measured progress toward recognition and avoidance of common failure modes. Since introducing this curriculum, the number of retained guidewires has fallen more than 4-fold. Rates of catheter-associated infections have not yet declined, and it will take time before ultrasound training will have a measurable effect.

Conclusion: The FMEA provided a process for curriculum development. Precise definitions of failure modes for retained guidewires facilitated development of a curriculum that contributed to a dramatic decrease in the frequency of this complication. Although infections and access complications have not yet declined, failure mode identification, curriculum development, and monitored implementation show substantial promise for improving patient safety during placement of central venous catheters.

Figure 1

Survey Data From the 2009 PGY-1 Trainees

Figure 2

Operational Data Regarding High-Priority Failure Modes Bar height for 2009 was based on data from the first 6 months of 2009—the total number of catheter placements throughout the institution is not known but is estimated to be approximately 10 000 per year throughout this period. Note: 2006 is the baseline—the number of retained guidewires has been tracked since 2006 and the number of catheter-associated bloodstream infections in patients in intensive care has been tracked since 2004; the first yearly training course was conducted in the summer of 2007.

Figure 3

Content From The Online Training Modules Panel A how catheter and guidewire skills were introduced using video with audio narration. The entire sequence was presented and later divided into segments that were practiced in detail. Panel B illustrates 1 of the 10 questions used in this module to assess whether the trainee knew the correct sequence of events. The learning management system used for this training was capable of automatically scoring such items. Panel C shows the introduction to the ultrasound interpretation module. The desired sequence was presented and a mapping analogy was used to help convey the steps needed to examine an ultrasound image and determine the optimal needle path. Panel D is 1 of the questions from this module's final exam and again uses the ordered list task model. In this example, path 3 is preferred because it minimizes the probability that the needle might be advanced too far and enter the red “safety zone” surrounding the carotid artery. Path 1 is the least desirable because the needle would be directed toward the carotid artery, and it also requires advancing the needle a greater distance than path 2.

Figure 4

Item Analysis for Final Exam in the Ultrasound Image Interpretation Module The average number of incorrect choices for each item was determined by examining the performance records captured using the online assessment's learning management system. For this analysis, trainees were divided into 5 categories based on their overall score during this assessment (best, >95%; better, 90% to 95%; good, 85% to 90%; fair, 80% to 85%; poor, <80%). These results illustrate how 4 test items (no. 3, 5, 17, and 18) account for most of the errors and how the probability of an error increases as student performance falls. Please note that item 3 from this assessment is presented in panel D of Figure 3.