Simulation-Based Mastery Learning for Thoracentesis Skills Improves Patient Outcomes: A Randomized Trial

Abstract

Purpose: Physicians-in-training often perform bedside thoracenteses in academic medical centers, and complications are more common among less experienced clinicians. Simulation-based mastery learning (SBML) is one potential solution to this problem. This study evaluated the effects of a randomized trial of thoracentesis SBML on patient complications: iatrogenic pneumothorax (IP), hemothorax, and reexpansion pulmonary edema (REPE).

Method: The authors randomized internal medicine residents to undergo thoracentesis SBML at a tertiary care academic center from December 2012 to May 2016. They subsequently compared thoracentesis complications from procedures performed by SBML-trained residents, traditionally trained residents (no simulation training), and those referred to pulmonary medicine or interventional radiology (IR).

Results: During the study period, 917 thoracenteses were performed on 709 patients. IP occurred in 60 (6.5%) procedures, of which 7 (11.6%) were clinically meaningful. SBML-trained residents performed procedures with a trend toward lower combined clinically meaningful complications (IP, hemothorax, REPE) compared with traditionally trained residents (7.9% vs. 0%; P = .06). SBML-trained residents caused fewer clinically meaningful IPs compared with traditionally trained residents, pulmonary, and IR referrals (P = .02). Hemothorax occurred after 4 (0.4%) thoracenteses, and SBML-trained residents had a trend toward lower hemothorax (0) compared with other groups (P = .07). REPE occurred after 3 (0.3%) procedures, with no differences between groups. SBML-trained residents performed procedures with lower combined clinically meaningful complications compared with other groups (P = .008).

Conclusions: Residents randomized to an SBML intervention performed thoracenteses with low rates of clinically meaningful complications. Rigorous education represents a successful quality improvement strategy.