Simulation-based procedural training for pediatric residents: one small step for a program … one giant leap for mankind!

www.pccmjournal.org November 2013 • Volume 14 • Number 9 In this issue of Pediatric Critical Care Medicine, Thomas et al (1) describe their efforts to train pediatric residents in central venous catheter (CVC) placement. They present pilot data demonstrating improved performance by pediatric residents immediately following didactic and hands-on task training on simulators. Trainee performance, however, substantially decayed by 3-month follow-up. Following the recommended simulation study description format (Sim PICO: Population, Intervention, Comparative group and Outcome measures) (2), the study population was pediatric residents (postgraduate year 1–3), the majority (22 of 26) without prior CVC placement experience. It is important to recognize that nonresident providers perform most CVC insertions in their institution and that CVC placement is not an Accreditation Council for Graduate Medical Education training requirement for pediatric residents (3). The study intervention was a combined didactic/simulation-based education session composed of a 10-minute instruction video and small group (1–3 residents per session) psychomotor skill training using ultrasound-compatible task trainers. This study uses a pre-post design due to the limited number of subjects and feasibility. Therefore, the comparator group was the same trainee providers before the intervention. The outcome measures included a task-based skill checklist and a global performance rating scale assessed by expert raters at preintervention, immediate postintervention, and 3 months post intervention. All raters were blinded to the subject’s training status, and assessment was done using review of key video segments. Although the rater training process was not described, the interrater reliability was good for both individual items and global ratings. This study emphasizes known strengths of simulation-based training: rapid acquisition of procedural skills for novices in a safe learning environment. If we allow pediatric residents to perform CVC placement on critically ill children, we need to ensure layers of safety mechanisms. Minimum support should at least include 1) initial skill acquisition in a risk-free environment, for example, simulation-based task training; 2) education of the safest method, for example, ultrasound guidance to minimize complications such as arterial puncture or pneumothorax (4); 3) training to competence or (ideally) mastery; and 4) minimize skill decay over time after initial training. This pilot study clearly addresses the first two layers of safety. At the same time, this study raises three important questions that may not be limited to simulation-based training: 1) How do we optimize initial training? 2) How do we optimize sustaining learned skills over time? and 3) How does our training translate to bedside performance on real patients? To answer to the first and second questions, Barsuk et al (5) used the concept of mastery learning in CVC insertion skill training for medical residents. Mastery learning is an especially stringent form of competency-based education whereby students must meet fixed high performance standards before progressing to the next stage of training or practice without time limitation (6). With a 1-hour didactic session and a 3-hour deliberate practice using simulators, 96% of residents achieved internal jugular CVC insertion skill mastery level on the training manikins. The remainder of the residents achieved mastery level on the manikins within an additional 1 hour of training. This mastery skill level on manikins was maintained at 6 months (82%) and 12 months (87%). At least for psychomotor skill acquisition, mastery learning is a very promising approach. Once mastery is achieved and then repeatedly used and reinforced in a clinical practice setting, the skill level seems to be sustained (7). In this pilot study, the pediatric resident group had a median global rating score of 80 on 0–100 mm scale immediately after training as assessed by raters. These raters were asked the likelihood of a subject successfully performing CVC placement without complication or issues with sterile technique. This score alone might explain poor skill retention at 3-month follow-up. In other words, the skills were not acquired well enough to be retained. One potential solution would be to set the initial training goal at a mastery level and allow residents to practice with appropriate feedback and remediation deliberately (repetitively with appropriate difficulty level) until the skills meet the mastery level. Another solution could be to use frequent refresher training, especially when the psychomotor skill is not used often in clinical practice between training and retesting (8, 9). It is important to note that frequent refresher training needs to be relatively brief and therefore not sufficient for initial skill acquisition (10). Copyright © 2013 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0b013e3182a54dbe Thomas Conlon, MD Vinay Nadkarni, MD, MS Akira Nishisaki, MD, MSCE Department of Anesthesiology and Critical Care Medicine The Children’s Hospital of Philadelphia Philadelphia, PA