A Systematic Approach to Teaching Insertion of a Central Venous Line

Abstract

Objective: With the tremendous technologic advances made in the last decade, medicine continues becoming increasingly invasive in its practice. With this comes the mandated responsibility for residency programs to prepare graduates to perform a core set of procedural skills. We implemented a 1.5-hour workshop as part of our Internal Medicine Colloquia Series with the intent of providing a standardized, pedagogic training ground for one of these core procedural skills —insertion of the central venous line (CVL). Description: In collaboration with faculty of the Department of Anatomy at the University of Hawaii John A. Burns School of Medicine, we were able to execute a multidisciplinary workshop with the goals of (1) effecting a positive change in residents' perceptions and attitudes about inserting CVLs, (2) improving their clinical knowledge regarding CVL insertion, and (3) improving their behaviors, represented by a decrease in procedure complication rates and by better chart documentation. Curricular content included areas of informed consent, indications and contraindications for CVL insertion, a systematic method of CVL insertion, insertion complications, and medical record documentation. First-year internal medicine and transitional residents were taught using methods such as interactive discussions, practical skills demonstrations, and a cadaver demonstration. The highlight of the workshop was the cadaver demonstration. The neck and upper thorax of a human cadaver were meticulously dissected to display the anatomic relationships particular to both the internal jugular and the subclavian vein approach to CVL insertion. The residents were able to simulate their systematic approaches to CVL insertion and receive immediate feedback on their attempts. Discussion: The residents have responded favorably to this workshop. Upon entry, they uniformly agreed that it was important to know how to insert a CVL, but most did not feel confident with their insertion technique, recognizing proper placement, or recognizing the associated complications. Comparison between entry and exit questionnaires has shown significant improvement (p < 0.05) in their comfort with the concepts of informed consent, insertion technique, recognition of proper placement, knowledge of the complications, and writing a proper procedure note. Statistically significant (p < 0.05) differences were also seen in their knowledge, based on an objective quiz administered before and after the work-shop that assessed indications for CVL insertion, technique, and complications. Assessment of behavioral change is being made via a chart review (in progress) to monitor complication rates and the quality of the procedure notes. As a result of this skills workshop, all the residents feel more confident in their abilities to insert a CVL and write a complete and accurate procedure note. They agreed that they not only had enjoyed the workshop but also recommended that it to be continued for future first-year classes. Our preliminary experience demonstrates that a systematic approach to CVL insertion as promoted through this workshop has a positive impact on residents' attitudes and knowledge. From this, it is anticipated that there will be a resultant improvement in the quality of patient care, including greater patient comfort and lower complication rates.