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Original Research: CRITICAL CARE |

Performance of Medical Residents in Sterile Techniques During Central Vein Catheterization: Randomized Trial of Efficacy of Simulation-Based Training FREE TO VIEW

Hassan Khouli, MD, FCCP; Katherine Jahnes, MD; Janet Shapiro, MD, FCCP; Keith Rose, MD; Joseph Mathew, MD; Amit Gohil, MD; Qifa Han, PhD; Andre Sotelo, MD; James Jones, MD; Adnan Aqeel, MD; Edward Eden, MD, FCCP; Ethan Fried, MD
Author and Funding Information

From the Department of Medicine (Drs Khouli, Shapiro, Rose, Han, Sotelo, Jones, Aqeel, and Fried), and the Division of Pulmonary, Critical Care, and Sleep Medicine (Dr Eden), St Luke’s-Roosevelt Hospital Center, New York, NY; the Department of Emergency Medicine (Dr Jahnes), New York Methodist Hospital, New York, NY; the Division of Pulmonary, Critical Care, and Sleep Medicine (Dr Mathew), Beth Israel Medical Center, New York, NY; and the Department of Medicine (Dr Gohil), Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA.

Correspondence to: Hassan Khouli, MD, Critical Care, St. Luke’s-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, 1000 10th Ave, Critical Care Administration, Suite 8C-05, New York, NY 10019; e-mail: hkhouli@chpnet.org


Funding/Support: This study was supported by internal departmental support from the Department of Medicine, St. Luke’s-Roosevelt Hospital Center.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(1):80-87. doi:10.1378/chest.10-0979
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Background:  Catheter-related bloodstream infection (CRBSI) is a preventable cause of a potentially lethal ICU infection. The optimal method to teach health-care providers correct sterile techniques during central vein catheterization (CVC) remains unclear.

Methods:  We randomly assigned second- and third-year internal medicine residents trained by a traditional apprenticeship model to simulation-based plus video training or video training alone from December 2007 to January 2008, with a follow-up period to examine CRBSI ending in July 2009. During the follow-up period, a simulation-based training program in sterile techniques during CVC was implemented in the medical ICU (MICU). A surgical ICU (SICU) where no residents received study interventions was used for comparison. The primary outcome measures were median residents’ scores in sterile techniques and rates of CRBSI per 1,000 catheter-days.

Results:  Of the 47 enrolled residents, 24 were randomly assigned to the simulation-based plus video training group and 23 to the video training group. Median baseline scores in both groups were equally poor: 12.5 to 13 (52%-54%) out of maximum score of 24 (P = .95; median difference, 0; 95% CI, 0.2-2.0). After training, median score was significantly higher for the simulation-based plus video training group: 22 (92%) vs 18 (75%) for the video training group (P < .001; median difference, 4; 95% CI, 3-6). During the follow-up period, there was a significantly lower rate of CRBSI in the MICU (1.0 per 1,000 catheter-days) compared with the SICU (3.4 per 1,000 catheter-days) (P = .03). The incidence rate ratio derived from the Poisson regression (0.30; 95% CI, 0.10-0.91) indicated there was a 70% reduction in the incidence of CRBSI in the postintervention MICU compared with the preintervention MICU and the postintervention SICU.

Conclusions:  Simulation-based training in sterile techniques during CVC is superior to traditional training or video training alone and is associated with decreased rate of CRBSI. Simulation-based training in CVC should be routinely used to reduce iatrogenic risk.

Trial Registry:  ClinicalTrials.gov; No.: NCT00612131; URL: clinicaltrials.gov.

Figures in this Article

Catheter-related bloodstream infection (CRBSI) is an important and preventable cause of nosocomial infections. It is estimated that 5% to 26% of patients experience an infectious complication from their central venous catheter.1 In the United States, an estimated 15 million catheter-days are spent in ICUs,2 and nearly 80,000 ICU patients develop CRBSI annually3 at a rate of approximately 1.2 to 5.6 infections per 1,000 catheter-days,4 resulting in as many as 28,000 deaths annually and increased hospital and ICU lengths of stay.5

The Centers for Disease Control and Prevention (CDC) have published evidence-based guidelines for the prevention of CRBSI.6 The interventions emphasize several distinct practices, including training health-care providers, using maximum sterile barrier precautions, correct hand washing, and the use of 2% chlorhexidine for skin preparation.6 Several studies demonstrated significant reductions (18%-100%) in CRBSI rates, mortality, and cost from the application of these strategies.5,7,8 However, the guidelines of the CDC, despite their seeming simplicity, are insufficiently applied, whether by ignorance or by omission.5

In most medical institutions, including ours, residents learn CVC by the apprenticeship model “see one, do one, teach one.” Although this method theoretically includes the use of sterile techniques (STs), the focus of teaching, and of residents’ primary interest, is the proper placement of the catheter.

Patient simulation is emerging as a valuable adjunct to traditional training methods and competence assessment in medical education, including CVC.9-14 Medical simulation allows residents repetitive and deliberate practice in a realistic and interactive environment that minimizes risk to patients. The use of audiovisual equipment in medical simulation to record residents’ performance gives valuable feedback and enables residents to visualize their missteps.15

We carried out a randomized, controlled, single-blinded investigation to assess: (1) baseline medical resident ST skills (apprenticeship model) during CVC, and (2) whether a medical simulation environment that replicates an ICU setting is more effective than traditional training methods to teach residents proper ST. In a separate observation we assessed the impact of simulation-based training on the rate of CRBSI in medical ICU (MICU).

Setting and Participants

We conducted a randomized controlled single-blinded study at a university-affiliated, 885-bed, urban teaching hospital between December 2007 and January 2008 with a follow-up period from February 2008 to July 2009. The study was approved by the hospital institutional review board (IRB#07-125). Subject informed consent was obtained from each resident who participated in the study. The study was performed in a simulation laboratory designed as an ICU/resuscitation room (Fig 1). Simulation laboratory settings are further described in e-Appendix 1. All sessions were videotaped.

Figure 2 illustrates enrollment and study flow. All second- and third-year (postgraduate year [PGY]-2 and PGY-3) internal medicine (IM) residents (50 residents) who were certified by their residency program in CVC were individually contacted and invited to participate in the study. Forty-seven residents agreed to participate in the study. The inclusion criteria for study participants were: (1) completion of 1 year of training in an IM residency program, and (2) a certification by their residency program in CVC (minimum of five procedures). Exclusion criterion was refusal to participate in the study. Prior to this study, all IM residents in our institution received training in CVC by the traditional apprenticeship method.

Figure Jump LinkFigure 2. Enrollment and study flow. MICU = medical ICU; PGY = postgraduate year; SICU = surgical ICU.Grahic Jump Location
Study Procedures
Development of Study Materials:

Based on current CDC recommendations,6 an ST assessment tool was developed by study investigators and included the following categories: nonsterile preparation, hand washing, sterile field/supply preparation, sterile gowning, sterile gloving, and sterile draping. Each category was assigned equal weighting in the analysis and had a minimum score of 0 and a maximum score of 4 with an overall maximum score of 24 points. The assessment tool is shown in e-Appendix 2, and study materials are detailed in e-Appendix 1.

For the purpose of this study and based on the above-described assessment tool, a 20-min video clip was developed in the simulation laboratory for video training. Subsequently, all observers trained and practiced in the simulation laboratory. Observers reviewed the method of scoring and individual steps on the assessment tool and underwent individually an assessment of their ST skills using the study assessment tool. Consensus and standardized method of scoring were agreed on among observers at the end of this exercise.

Randomization of Study Residents:

Residents who agreed to participate in the study were randomized to simulation-based plus video training or video training alone. Allocation of subjects to each group was concealed. The detailed randomization process is outlined in e-Appendix 1.

CRBSI Data Collection:

In a separate observation, we reviewed CRBSI data. These data were collected monthly by trained, hospital-based infection control practitioners who were not study investigators. The National Healthcare Safety Network definition16 was used as the basis for definition of CRBSI. Mean rates of CRBSI in the MICU (22 beds) and surgical ICU (SICU) (16 beds) were compared 18 months before and after completion of the study intervention. Full description of standard procedures for prevention of CRBSI implemented in the MICU and SICU prior to this study intervention are outlined in e-Appendix 1. To determine whether changes in the severity of illness might impact rates of CRBSI, we compared the APACHE (Acute Physiology and Chronic Health Evaluation) II scores of all patients admitted to the MICU with central lines before and after study intervention.

Study Interventions:

During study phase I period, each of the 47 residents individually underwent baseline assessment of their performance in ST in the simulation laboratory. A self-evaluation survey to assess the resident’s sense of preparedness and confidence in ST during CVC was administered to all study residents before study phase I. During study phase II period, residents received education and training according to their randomized group. After completion of video training or simulation-based plus video training, all residents underwent reassessment of their ST skills. Full description of study intervention procedures is outlined in e-Appendix 1.

Follow-up Period Interventions:

After the completion of study phase II period and immediately after the results of the randomized educational intervention were known, a simulation-based training program in ST during CVC was implemented. All the physicians in the MICU, including rotating IM residents who did not receive simulation-based training in ST as part of the study intervention, were provided simulation-based training in ST during the postintervention follow-up period. During this follow-up period, a second group of 58 additional IM residents trained by the traditional apprenticeship model underwent baseline assessment of their ST followed by simulation-based training plus video training in the simulation laboratory. All emergency medicine residents were also provided simulation-based training plus video training in ST in the follow-up period.

Study Outcomes

The primary study outcome was median IM resident’ scores in ST. The secondary outcome was the rate of CRBSI in the MICU and SICU.

Statistical Analysis

The effect of simulation-based training on performance was evaluated at the end of phase II by comparing median ST scores of the video training group with that of the simulation-based plus video training group. A Wilcoxon signed-rank test was used for group comparison and to compare median scores improvement in the 58 additional residents in the follow-up period. The difference in medians was estimated using the methodology of Hodges-Lehmann.17

Fisher exact test was performed on an all-or-none analysis (ie, number of residents with perfect score [4] vs nonperfect [0-3 score] for each ST category in each group according to randomization). The interobserver agreement between the two observers who scored residents was measured by Cohen κ coefficient. The rate of CRBSI was analyzed by fitting a generalized linear model. The likelihood of infection as a function of ICU type (MICU vs SICU) and study period (preintervention and postintervention) were examined by Poisson regression modeling, including the number of catheter-days as an exposure variable. Two-sample t test was performed to compare mean APACHE II scores between preintervention and postintervention periods.

P values < 0.05 were considered statistically significant. All statistical analyses were executed using SAS 9.1 (SAS Institute; Cary, North Carolina).

A total of 47 IM residents completed phase 1 and II of this study. Twenty-four residents were randomized to the simulation-based plus video training group, and 23 residents were randomized to the video training group. The interobserver agreement between the two observers was 0.98 (CI, 0.97-0.99; P < .001).

Table 1 is a summary of median scores in each of the six ST categories and total scores in phases I and II according to group randomization. Traditionally trained residents’ median baseline scores in both groups were equally poor: 12.5 to 13 (52%-54%) out of maximum score of 24 (P = .95; median difference, 0; 95% CI, 0.2-2.0). In phase II, median score was 22 (92%) for simulation-based plus video training group vs 18 (75%) for video training group (P < .001; median difference, 4; 95% CI, 3-6).

Table Graphic Jump Location
Table 1 —Summary of the 47 Residents’ Median Scores in Each of the Six Sterile Technique Categories and Total Scores in Phases I and II According to Randomization: Video Training Group (23 Residents) vs Simulation-Based + Video Training Group (24 Residents)
a 

Median total score: minimum (0) and maximum (24).

b 

Median score: minimum (0) and maximum (4).

c 

Difference in median scores between video training group and simulation-based + video training group in phase I and in phase II.

Table 2 is a summary of an all-or-none analysis performed on each ST category in the video training group and simulation-based plus video training group at study phases I and II (number of residents who had perfect score in each of the six ST categories). There was no statistically significant difference between the groups in any of the six ST categories at baseline (P > .05). In phase II, there was a statistically significant difference in four of six of the median ST categories scores between video training group and simulation-based plus video training group (P < .001); in each of these differences the simulation-based plus video training group scores were higher.

Table Graphic Jump Location
Table 2 —All-or-None Analysis: Comparisons of Number of Residents With Perfect Scores in Each of the Six Sterile Technique Categories Between Video Training Group and Simulation-Based + Video Training Group
PGY Training Level Analysis

Analysis of ST performance between PGY-2 and PGY-3 residents was performed. There was no statistically significant difference between PGY-2 and PGY-3 residents in total and subcategory scores in each study phase (P > 0.5).

Baseline Survey Results

Table 3 shows results of the survey administered to the 47 participating IM residents. The majority of residents believed they had received sufficient training in the placement of central lines overall and in the use of maximum sterile barrier precautions. There was no statistically significant difference in any survey question either between the video training group and the simulation-based plus video training group or between PGY2 and PGY3 residents.

Table Graphic Jump Location
Table 3 —Results of the Study Survey According to the Two Groups: Video Training Group (23 Residents) and Simulation-Based + Video Training Group (24 Residents)

Data are presented as No. (%).

a 

P value > 0.05, comparison between video training group and simulation-based + video training group in all eight question categories.

Follow-up Study Period

Fifty-eight additional IM residents trained by traditional apprenticeship model underwent baseline assessment of their ST followed by simulation-based training plus video training in the simulation laboratory. Median total baseline score of the 58 residents was 13 and improved to a median total score of 24 (P < .001) after simulation-based training plus video training.

CRBSI Results

Prior to the study intervention, there were 3.5 infections per 1,000 catheter-days (20 catheter infections in 5,702 catheter-days) in the MICU and 3.6 infections per 1,000 catheter-days (12 catheter infections in 3,301 catheter-days) in the SICU. After study intervention, the mean rate of CRBSI in the MICU was reduced to 1.0 per 1,000 catheter-days (five catheter infections in 4,912 catheter-days). However, the surgical ICU mean rate of CRBSI remained unchanged at 3.4 per 1,000 catheter-days (eight catheter infections in 2,352 catheter-days) (Fig 3). None of the CRBSI in the preintervention or postintervention periods was related to catheters placed in the femoral site or to catheters placed in the emergency department.

Figure Jump LinkFigure 3. Rate of catheter-related bloodstream infections over time in MICU and SICU (comparison ICU) before and after study intervention. Areas between dotted vertical lines represents study intervention period. See Figure 2 legend for expansion of abbreviations.Grahic Jump Location

After study intervention, there was a significantly lower rate of CRBSI in the MICU than in the SICU (P = .03). The incidence rate ratio derived from the Poisson regression (0.30; 95% CI, 0.10-0.91) indicates there was a 70% reduction in the incidence of CRBSI in the postintervention MICU compared with the preintervention MICU and the postintervention SICU. There was trend toward increased mean APACHE II scores in the postintervention period, but the difference was not statistically significant in mean APACHE II scores for MICU patients with CVCs between the postintervention period (23.8 ± 8.7) and the preintervention period (23.1 ± 8.6) (P = .06). There was no statistically significant difference in mean APACHE II scores for SICU patients with CVCs between the preintervention period (20.1 ± 8.2) and the postintervention period (20.3 ± 8.3) (P = .3).

The major focus of our investigation was to determine whether simulation-based training in sterile technique during CVC was more effective than traditional training or video training alone. We also assessed the impact of the follow-up simulation-based training program we implemented after study intervention in our MICU on the rate of CRBSI. We found that simulation-based training in ST during CVC is superior to a traditional training (apprenticeship) method or video training alone. Simulation-based training in ST resulted in improved IM residents’ performance and 70% decrease in the rate of CRBSI in the MICU. We implemented study results found in the initial randomized educational period to a second group of IM residents during the study follow-up period with reproducible results.

In our study, the baseline performance in ST during CVC was consistent with reported compliance rates ranging from 16% to 81%.18-21 Others22 have found that only 22% of physicians-in-training believed full sterile drape was necessary during CVC. Despite having traditional procedures already in place to teach residents, we observed frequent violations of ST, and using a checklist for adherence to basic ST7,8 may not capture these important violations.

Simulation-based training addresses several aspects of the learning process. The process breaks down the procedure into all of its parts and then puts together the different components. The viewing of a video recording of the individual’s own performance provides insight in a way that no other technique allows: on seeing his or her own performance, the learner has a moment of recognition of his or her own error or breach in technique (eg, I do not have a mask on; I did not have my sterile gown tied and the gown is flailing and contaminating the sterile field; I did not wash my hands before the procedure; I did not put on my sterile gloves correctly; and so forth). The learner viewing of his or her own performance on video provides a realistic view of the performance. Debriefing based on the video of the subject’s own work combined with constructive feedback would therefore be a most advantageous means of education.

Educating health-care providers to prevent CRBSI may decrease the rate of these infections.2,5,23-28 One recent review by Safdar and Abad29 identified 26 studies that used different educational programs and targeted various health-care providers. Although several of the identified studies showed reduction in CRBSI after education, the authors concluded that most of the studies reviewed suffered from lack of randomization and detailed description of the learners, interventions, and data collection used. Because simulation training has been increasingly recognized as a useful training tool, few recently published studies demonstrated the efficacy and usefulness of simulation-based training in CVC.9-14 Such cumulative data combined with the results of our study effectively support the use of simulation-based training in ST during CVC as first-line training method.

Traditional lecture-based training can effectively translate knowledge and may result in meaningful behavioral changes.30 Xiao et al19 found that clinicians provided video training in ST were more likely to fully comply with sterile practice than groups provided written or no training (74% vs 33%; OR, 6.1). None of these studies used simulation-based training or a simulation environment that resembles clinical settings to assess and train subjects as was done in our study.

Simulation-based training would appear to provide the ideal environment for educating clinicians about ST. Barsuk et al8 recently published a study that showed the effectiveness of a simulation-based training program in reducing CRBSI. This study did not evaluate any training alternatives to simulation, there was no training randomization, and there was no baseline assessment of resident’s performance before training reported in this article. In the accompanying editorial,31 Quinn stated there was a need to demonstrate if simulation training is far superior to other methods in teaching ST. Nevertheless, our study results provide additional evidence shown by Barsuk et al8 for the effectiveness of simulation-based training in ST during CVC.

Our objective findings of inadequate ST performance dramatically contrasted with IM residents’ perception of their competence. In our survey, a majority of residents reported they received sufficient training in the placement of central lines and in the use of ST. Surveys in medical education training have documented discrepancies between resident perception and objective skills, such as CPR skills.32,33 As a corollary, we found no difference in performance in ST according to resident level of training. This may be explained by the fact that practices are learned early in training and do not change. Simulation-based training in ST performed early in a training program may thus have a significant impact on lifelong learning and patient safety.

In our study we noted significant reduction in CRBSI in the MICU 18 months after study completion. This is likely to be attributed to our study intervention and the implementation of a simulation-based training program in the MICU in the postintervention period, as no other intervention aimed at reducing CRBSI was introduced in the MICU during the data collection, and is further supported by the lack of improvement in the rate of CRBSI in the SICU staffed by surgery residents who did not undergo either video training or simulation-based training.

Our study is unique in the blinded randomized design of the initial educational intervention, the use of several CDC-recommended ST steps, and the full implementation of a simulation-based training program using an ICU simulation laboratory. Randomized educational studies are limited by the required short duration of the educational intervention to prevent confounders such as cross-contamination between study groups, as residents may discuss study designs and interventions they are receiving. We designed our study so each study phase was done rapidly to prevent such confounder.

The study has several limitations. First, we had the benefit of a dedicated simulation laboratory, which may not be available in other hospitals. However, simulation-based training can be provided in less formal and costly settings with access to audiovisual equipment and mannequins. Second, our study did not establish if simulation-based training without the addition of video training would have been sufficient. The use of a video in the training of residents randomized to the simulation-based training was designed to be complementary to visual learners, whereas we suggest the essential educational element was the simulation-based training. Third, it is possible the reduction in rate of CRBSI observed after training in our study is partially due to the behavior of the ICU staff after the study; specifically, residents and faculty who participated in the study might have promoted a more conscientious approach to sterility in performing such a procedure in the MICU. Nevertheless, any behavioral change was a direct consequence of this study and similar simulation-based training extended to our MICU staff in the follow-up period. Fourth, we could not assess knowledge retention in residents who participated in the study. After realizing the significant deficiencies in ST skills among our IM residents, we implemented simulation-based educational program in our MICU where IM residents rotating in the MICU were subject to further simulation-based training in ST in the simulation laboratory as was reported in our study results. Additionally, the possible full impact of simulation-based intervention could not be obtained as the mannequin used (as depicted in Fig 1) was not designed for landmark or ultrasound-guided CVC, possibly limiting the experiential training to that of ST.

Our study offers a broader viewpoint on medical education. Many years of experience with infection control investigations have shown us that instruction of physicians-in-training varies widely. The apprenticeship model of “see one, do one, teach one” facilitates different standards and potentially acceptance of incorrect practices. Our study confirms that simulation-based training in sterile techniques during CVC is superior to traditional training or video training alone and is associated with decreased rate of CRBSI. Simulation-based training in CVC should be routinely used to reduce iatrogenic risk.

Author contributions: Dr Khouli had access to and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Khouli: contributed to study conception and design, data collection, analysis and interpretation of the data, drafting of the manuscript, and critical revision of the article for important intellectual content.

Dr Jahnes: contributed to study design, data collection, data analysis and interpretation, reviewing, editing, and section writing of the manuscript.

Dr Shaprio: contributed to study design, data collection, data analysis and interpretation, reviewing, editing, and section writing of the manuscript.

Dr Rose: contributed to study design, data collection and analysis, reviewing, editing, and section writing of the manuscript.

Dr Mathew: contributed to study design, data collection and data interpretation, reviewing, editing, and section writing of the manuscript.

Dr Gohil: contributed to study design, data collection, interpretation of the data, reviewing, and editing of the manuscript.

Dr Han: contributed to study design, analysis and interpretation of the data, reviewing, editing, and section writing of the manuscript.

Dr Sotelo: contributed to study design, data collection and interpretation, reviewing, editing, and section writing of the manuscript.

Dr Jones: contributed to data collection, analysis and interpretation of the data, reviewing, and editing of the manuscript.

Dr Aqeel: contributed to data collection, analysis and interpretation of the data, reviewing, and editing of the manuscript.

Dr Eden: contributed to interpretation and analysis of the data, reviewing, editing, and section writing of the manuscript.

Dr Fried: contributed to study design, interpretation and analysis of the data, reviewing, editing, and section writing of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Additional Information: The e-Appendices can be found in the Online Supplement at http://chestjournal.chestpubs.org/content/139/1/80/suppl/DC1.

APACHE

Acute Physiology and Chronic Health Evaluation

CDC

Centers for Disease Control and Prevention

CRBSI

catheter-related bloodstream infection

CVC

central vein catheterization

IM

internal medicine

MICU

medical ICU

PGY

postgraduate year

ST

sterile technique

SICU

surgical ICU

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Rosenthal VD, Guzman S, Pezzotto SM, Crnich CJ. Effect of an infection control program using education and performance feedback on rates of intravascular device-associated bloodstream infections in intensive care units in Argentina. Am J Infect Control. 2003;317:405-409. [CrossRef] [PubMed]
 
Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med. 2008;363:933-940. [CrossRef] [PubMed]
 
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systemic review of the effect of continuing medical education strategies. JAMA. 1995;2749:700-705. [CrossRef] [PubMed]
 
Quinn J. Catheter-related bloodstream infections: the challenge to do better. Arch Intern Med. 2009;16915:1353-1354. [CrossRef] [PubMed]
 
Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;357:1668-1672. [CrossRef] [PubMed]
 
Dine CJ, Gersh RE, Leary M, Riegel BJ, Bellini LM, Abella BS. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med. 2008;3610:2817-2822. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 2. Enrollment and study flow. MICU = medical ICU; PGY = postgraduate year; SICU = surgical ICU.Grahic Jump Location
Figure Jump LinkFigure 3. Rate of catheter-related bloodstream infections over time in MICU and SICU (comparison ICU) before and after study intervention. Areas between dotted vertical lines represents study intervention period. See Figure 2 legend for expansion of abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Summary of the 47 Residents’ Median Scores in Each of the Six Sterile Technique Categories and Total Scores in Phases I and II According to Randomization: Video Training Group (23 Residents) vs Simulation-Based + Video Training Group (24 Residents)
a 

Median total score: minimum (0) and maximum (24).

b 

Median score: minimum (0) and maximum (4).

c 

Difference in median scores between video training group and simulation-based + video training group in phase I and in phase II.

Table Graphic Jump Location
Table 2 —All-or-None Analysis: Comparisons of Number of Residents With Perfect Scores in Each of the Six Sterile Technique Categories Between Video Training Group and Simulation-Based + Video Training Group
Table Graphic Jump Location
Table 3 —Results of the Study Survey According to the Two Groups: Video Training Group (23 Residents) and Simulation-Based + Video Training Group (24 Residents)

Data are presented as No. (%).

a 

P value > 0.05, comparison between video training group and simulation-based + video training group in all eight question categories.

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Rosenthal VD, Guzman S, Pezzotto SM, Crnich CJ. Effect of an infection control program using education and performance feedback on rates of intravascular device-associated bloodstream infections in intensive care units in Argentina. Am J Infect Control. 2003;317:405-409. [CrossRef] [PubMed]
 
Safdar N, Abad C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med. 2008;363:933-940. [CrossRef] [PubMed]
 
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systemic review of the effect of continuing medical education strategies. JAMA. 1995;2749:700-705. [CrossRef] [PubMed]
 
Quinn J. Catheter-related bloodstream infections: the challenge to do better. Arch Intern Med. 2009;16915:1353-1354. [CrossRef] [PubMed]
 
Hayes CW, Rhee A, Detsky ME, Leblanc VR, Wax RS. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. Crit Care Med. 2007;357:1668-1672. [CrossRef] [PubMed]
 
Dine CJ, Gersh RE, Leary M, Riegel BJ, Bellini LM, Abella BS. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med. 2008;3610:2817-2822. [CrossRef] [PubMed]
 
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