Patient Safety and Quality

Nonphysicians can be trained to assess residents' competence in catheter insertion

Residents are increasingly being taught hand-eye coordination skills through partial task simulators of catheter insertion and other practices that are potentially hazardous to patients. However, evaluation of the transfer of simulator training to actual patients can be difficult, because of the need to avoid bias on the part of clinician-instructors and to protect patient privacy. Leigh V. Evans, M.D., of Yale University School of Medicine, and colleagues found that undergraduate students, graduate students, and nursing and medical students who went through a 2-hour training course and a 2-hour testing session, could reliably rate residents' competence in performing ultrasound-guided insertion of a central venous catheter (CVC) on patients.

The researchers recruited 49 applicants to be trained as independent raters (IRs) of CVC procedures, and 38 of these applicants (78 percent) were selected to go through the training. The trainees went through a 2-hour session to teach them what was involved in CVC insertion and potential problems. They subsequently returned for an additional 2 hours to watch 5 of 10 choreographed videotapes of CVC insertion. The researchers evaluated the IR trainees on their ability to time the procedure, to accurately complete a 50-item checklist, and to identify all technical errors or complications shown in the video. Twenty-seven of the trainees (71 percent) were hired at $12.00/hr to evaluate the quality of residents' CVC insertions on actual patients. The hired trainees had 97 percent agreement with the standard answer on the 50 procedural checkpoints observed. The only difference between the observations of the IRs and a clinically trained research associate had to do with the number of times the resident's hand left the guidewire.

The researchers did not find an association between the educational level of the trainees (undergraduate versus some postgraduate education) and whether or not the trainee was hired. There was also no difference between medical student trainees and all other trainees on the likelihood of being hired. Use of the IRs will permit evaluation of the effectiveness of the simulation training on developing CVC skills in residents, and is likely to prove useful in evaluating other procedural skills of residents or medical students in the hospital setting, the researchers suggest. The study was funded in part by the Agency for Healthcare Research and Quality (HS16725).

More details are in "The development of an independent rater system to assess residents' competence in invasive procedures," by Dr. Evans, James L. Morse, M.D., Cara J. Hamann, M.P.H., and others in the August 2009 Academic Medicine 84(8), pp. 1135-1143.

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