Using Serious Gaming to Improve the Safety of Central Venous Catheter Placement: A Post-Mortem Analysis

Introduction To The Central Venous Catheter

Approximately 5 million central venous catheters (CVCs) are placed by physicians annually in the United States.(Gould, 2003) These catheters are often placed in critically ill patients to infuse potent medications, blood products, and/or to provide high concentration total parenteral nutrition (TPN). CVC’s are placed under sterile conditions, usually with ultrasound guidance, in a repetitive technical pattern. Regrettably, as with any medical procedure, complications occur; in this case at a rate of anywhere between 5%-26% of the time (Merrer, De Jonghe & Golliot, 2001; Raad, Darouiche & Dupuis, 1997). Common complications due to CVC placement include infection, pneumothorax (air trapped in the lung), arterial puncture (carotid, subclavian, or femoral vessels), thrombosis (local blood clot) and embolism (mobile blood clot) with occurrence rates that are often inversely correlated with clinical experience.(Fares & Block PH, 1986; Sznajder, Zveibil, Bitterman & Weiner, 1986) The subsequent costs of catheter-related complications are high, with a single catheter-related infection, for example, costing between $4,000 - $56,000.(H. S. et Al, 2010) Guidelines and recommendations are continually being established and updated regarding CVC placement in an attempt to minimize these complications, including the use of principles such as aseptic technique and antibiotic-coated catheters.(Anesthesiology, 2010) While much has been done regarding training practitioners in the technical skills of CVC placement using part-task trainers (i.e., mannequins)(Dong, Suri, Cook, Kashani, Mullon, Enders, Rubin & Ziv, 2010; Rosen & Uddin, 2009), successfully locating and cannulating a central vein is but one part of the process. In fact, many key steps designed to prevent untoward effects involve non-technical skills such as proper hand hygiene technique, ergonomic kit set up, and manometry are learned by practitioners through an apprenticeship model (i.e., see one, do one, teach one) which can lead to non -standardized practices or even perpetuate poor practices.

Healthcare practitioners are increasingly being trained in realistic and highly interactive simulated environments so they can learn not only psychomotor skills (e.g., lumbar puncture, endotracheal intubation), but also key management and non-technical steps which make their tasks safer (Toff, 2010). Simulation, for example, has been proven an effective teaching tool in a variety of healthcare environments including laparoscopy (Aggarwal, Ward & Balasundaram, 2007; Fried, Feldman & Vassiliou, 2004), bronchoscopy (Blum & Powers, 2004), and in team-training exercises in areas such as ACLS (Fletcher, Flin, McGeorge, Glavi & Maran, 2003; Wayne, Didwania, Feinglass, Fudala & Barsuk, 2008). Additionally, it has been shown that skill retention when using simulators is often superior to standard practices and that the use of simulation reduces the learning curve of many standardized procedures.(Andreatta P, Chen Y, Marsh M, 2010; Stefanidis D, Korndorffer J, Sierra R, 2005) Likewise, it has been shown that not only can simulators improve outcomes, but they can improve efficiency of performing procedures as well (Aggarwal, Ward & Balasundaram, 2007; Barsuk, McGahie, Cohen, Balachandran, 4AD; Britt & Reed, 2007). One specific simulation modality that has yet to be fully utilized to improve performance is serious gaming.