A Checklist for a Central Venous Line-Based Simulation Scenario to Measure Behavioral Compliance With Joint Commission National Patient Safety Goals

DEMOGRAPHICS Case Title: Central Venous Line Station. Patient Name: John Mitford. Scenario Name: Central Venous Line Station to Measure Behavioral Compliance With National Patient Safety Goals. Simulation Developers: Luise I.M. Pernar, MD; Tim J. Shaw, PhD; Sarah E. Peyre, EdD. Dates of Development: September to October 2009. Learning Group: Residents, postgraduate years 1–5. Specialties: Anesthesiology, Medicine, Surgery, Obstetrics/Gynecology, Emergency Medicine, Neurology, Psychiatry. CURRICULAR INFORMATION Educational Rationale After the publication of the sentinel work “To Err is Human”1 in 1999, the Joint Commission (JC) issued its first iteration of the National Patient Safety Goals (NPSGs) in 2003. Standards have evolved since, and the JC currently endorses 12 NPSGs in addition to the Universal Protocol.2 Healthcare organizations are responsible for ensuring that their employees are familiar with and follow the established guidelines, but how they do this varies by site and resources. Traditionally, written tests have been used for this assessment; however, written tests focus on cognitive knowledge and decision making and do not measure performance of behaviors that demonstrate an understanding of the NPSGs. We believed that assessment that incorporates observing behaviors associated with the NPSGs would be an appropriate complimentary form of assessment. Simulation Scenario Development To meet the goal of designing a simulation scenario that could be used to measure adherence to behaviors associated with the NPSGs, the NPSGs were initially outlined. A panel of experts including two educational psychologists, a surgeon, and a patient safety expert reviewed the goals and matched them to observable behaviors. A repeat review revealed that a scenario around central venous line (CVL) insertion would be the most comprehensive simulation scenario, allowing observation of most of the behaviors endorsed by the JC. In this fashion, goals around handoff, patient identification, compliance with hand hygiene, use of evidence-based practices to prevent central line-associated blood stream infections, labeling of medications, and the universal protocol were included in the scenario. Once we had defined the NPSGs to be included in the scenario, a corresponding checklist was created (Table 1). The checklist was reviewed for content by a patient safety expert (T.J.S.) and format by a surgical educator (S.E.P.). The checklist was evaluated in practice sessions in the simulation center.3Table 1: Checklist for Simulation ScenarioIn addition to suiting the purpose of the simulation station, using CVL insertion was advantageous because CVL insertion is a well-established simulation task. For instance, studies have shown that the use of simulation when teaching CVL insertion reduces technical complications4 and blood stream infections.5 There has also been an effort to use simulation to assess competency in central line placement.6,7 While including steps of preparation for central line placement, the assessment instruments used in these studies focused primarily on technical aspects of central line insertion, which appears appropriate for those studies. In adapting a simulation scenario around CVL insertion to specifically test adherence to the NPSGs, the aim was to divorce the mechanics of the task from the behaviors focused on patient safety. This was done to provide meaningful assessment of knowledge rather than technical skill as to allow measurement of adherence to NPSGs even in those trainees who have not yet received training in CVL insertion (ie, interns) or in those trainees who perform procedures but would not place CVLs specifically (eg, residents in psychiatry). Thus, this simulation scenario and focused checklist were specifically developed to evaluate learner's adherence to the NPSGs using the context of CVL placement. For the scenario, we chose a full-body mannequin for several reasons: to increase authenticity of the scenario of a patient in the intensive care unit (ICU) and to place a patient identification wristband on the mannequin. The authors felt that using a partial-task mannequin might cause the learner to focus on task performance and not the global care of the patient. Running the Scenario The scenario begins with a faculty member outside the “patient room” instructing the learner that they have a patient in the ICU who requires insertion of a CVL. It was explicitly stated that the learner did not know the patient and he/she should proceed as they would with any patient in the inpatient setting. A confederate in the room acted as the ICU nurse and learners were told that the nurse could answer questions and obtain any necessary equipment. An additional confederate was available outside the room should the learner being evaluated have additional questions or request supervision. In the room, the mannequin was intubated and was wearing a patient identification wristband. Patient chart, hand sanitizer, hats, masks, gown, and gloves, as well as a CVL kit including appropriate drapes, were also available in the room. The vial of lidocaine from the CVL kit was replaced with an unlabeled medication vial. The kit did not contain solution for skin cleansing, but the nurse carried chlorhexidine sticks that she gave to the learner if requested. The scenario was stopped before participants placed the CVL. Checklist The checklist is used to track performance as demonstrated, attempted, and not demonstrated; refer Table 1 for expected behaviors that a learner should demonstrate in the simulation scenario. “Attempted” in this context refers to a learner demonstrating a behavior outlined in the checklist (Table 1) but not carrying it out appropriately or completely; for instance, checks patient wristband but does not check the patient identifiers against another source. Recording demonstrated behaviors as well as those attempted or not demonstrated is most useful to give the learner appropriate feedback about performance. The checklist is intended for formative feedback and not to identify competence. As we did not expect CVL placement during our scenario, use of ultrasound or use of drapes were not explicitly included in the checklist. The scenario can be completed quickly; typically learners take approximately 7 minutes to complete the station. Rater training can be accomplished readily by explaining the checklist and showing a sample videotape of the simulation scenario. Learning Objectives Accreditation Council for Graduate Medical Education general competencies are as follows: Medical knowledge Recognize chlorhexidine as appropriate for skin sterilization Patient care Use proper patient identification Perform hand hygiene Adhere to sterile technique Perform a safety pause Practice-based learning and improvement Participate in debriefing session Discuss NPSGs Interpersonal and communication skills Appropriately state need for additional sign out Ask nurse for additional equipment Communicate concern about inappropriate supplies and propose solutions Professionalism Demonstrate appropriate teamwork Provide quality care Systems-based practice Display behaviors consistent with the NPSGs Guided Study Questions None. Assessment Instrument NPSG checklist (Table 1). PREPARATION Staff Ideally, three individuals are available to run the scenario: A “nurse” is available in the room to answer questions, to provide or obtain additional materials, or to assist with the procedure. In addition, a “fellow” or “attending” should be available outside the room in case the resident asks for assistance or requests senior staff presence. A simulation specialist should be available to run the mannequin's vitals. The simulation specialist may not be necessary beyond starting the scenario, as there is no need to change physiological parameters. Monitors Required Noninvasive blood pressure cuff Pulse oximeter Other Equipment Required Mannequin with intubatable head as the “patient” in this scenario is intubated. To lend realism to the scenario, patient monitors should be in place. However, as the scenario is static and the “patient” is intubated, the mannequin need not have functional lungs or palpable pulses, and there is also no need for operator-controlled voice. Endotracheal tube Patient identification wristband Patient chart containing H&P and procedure consent Hand sanitizer Hats/caps Masks Sterile gloves Sterile gowns Chlorhexidine swab stick Central line kit containing all equipment necessary for central line placement and an unlabeled medication vial Supporting Files NPSG checklist (Table 1). Time Duration Setup: 5 minutes Preparation: 1 minute Simulation: 10 minutes Debrief: 20 minutes SIMULATION EXERCISE Case Stem A central line needs to be placed on a patient in the ICU. The patient's name is Mitford. You have not met the patient before. The fellow admitted the patient overnight for critical changes in the patient's respiratory status. Since admission, an endotracheal tube had to be placed to support respiratory function, and the patient is appropriately sedated. The decision has been made that a central line should be placed. All equipment you need is in the room or can be obtained if requested. A central line kit has been opened. The nurse in the room can answer any questions you might have or can get you anything else you need. Please proceed as you would if you were to place a central line on an actual patient in one of the hospital's ICUs. Background and Briefing Information for Facilitator/ Coordinator's Eyes Only Mr. Mitford is a 75-year-old man who has been in the hospital 3 days since undergoing a low anterior resection for recurrent colon cancer. After initially doing well, he received several boluses of intravenous fluid for hypotension on the floor and then became progressively more short of breath with increasing oxygen requirement. He was therefore transferred to the ICU. Progression of symptoms necessitated intubation. A central line is being placed to guide fluid therapy. A learner has been asked to place a central line on this patient. The trainee is unfamiliar with the patient and has not been given pertinent background information. The trainee should demonstrate behaviors consistent with adherence to the NPSGs in preparing to place the central line. This should include requesting information about the patient, including contraindications for CVL placement, proper hand hygiene before patient contact and before sterile technique, proper patient identification, proper barrier precautions, request of chlorhexidine for skin preparation, performance of a complete safety pause, and identification of an unlabeled medication vial as unacceptable for use. The trainee does not place the line during this simulation; it is “all about the prep.” Patient Data Background and Baseline State Patient History The patient is a 75-year-old man who underwent a low anterior resection for recurrent colon cancer 3 days before transfer to the ICU. He initially did well on the floor but has become progressively more short of breath with increasing oxygen requirement after receiving bolus intravenous fluid for hypotension on the floor. He was transferred to the ICU for further management. On admission, he confirmed shortness of breath. He denied fevers, chest pain, abdominal pain, nausea, vomiting, and diarrhea. He has since been intubated. Medical history: Obstructing colon cancer, hypotension, hypercholesterolemia, right-sided subclavian vein stenosis 2/2 previous port placement. Surgical history: Left subclavian port placement (now removed); sigmoid colectomy; laparoscopic cholecystectomy; right knee replacement. Current medications (in hospital): Fentanyl; Versed; Lopressor 5 mg iv q4 hours; Pepcid 20 mg iv bid; Heparin 5000 U sc q8 hours. Allergies: Rash from penicillin. Physical Examination Vital signs: Temperature 98.8°F, heart rate 89 bpm, blood pressure 145/68 mm Hg, respiratory rate 20/min, oxygen saturation 100% (intubated and ventilated) General: Intubated and sedated Heart: Regular rate, rhythm Lungs: Bilateral crackles, no wheeze Laboratory, Radiology, and Other Relevant Studies Platelets: 165,000/μL International Normalized Ratio: 1.2 Chest x-ray: Bilateral hazy infiltrates with prominent vascular markings; trace pleural effusion bilaterally; consistent with pulmonary edema (see Supplemental Digital Content 1, https://links.lww.com/SIH/A18).