Prepackaged central line kits reduce procedural mistakes during central line insertion: a randomized controlled prospective trial

BACKGROUND: Central line catheter insertion is a complex procedure with a high cognitive load for novices. Providing a prepackaged all-inclusive kit is a simple measure that may reduce the cognitive load. We assessed whether the use of prepackaged all-inclusive central line insertion kits reduces procedural mistakes during central line catheter insertion by novices. METHODS: Thirty final year medical students and recently qualified physicians were randomized into two equal groups. One group used a prepackaged all-inclusive kit and the other used a standard kit containing only the central vein catheter and all other separately packaged components provided in a materials cart. The procedure was videotaped and analyzed by two blinded raters using a checklist. Both groups performed central line catheter insertion on a manikin, assisted by nursing students. RESULTS: The prepackaged kit group outperformed the standard kit group in four of the five quality indicators: procedure duration (26:26 ± 3:50 min vs. 31:27 ± 5:57 min, p = .01); major technical mistakes (3.1 ± 1.4 vs. 4.8 ± 2.6, p = .03); minor technical mistakes (5.2 ± 1.7 vs. 8.0 ± 3.2, p = .01); and correct steps (83 ± 5% vs. 75 ± 11%, p = .02). The difference for breaches of aseptic technique (1.2 ± 0.8 vs. 3.0 ± 3.6, p = .06) was not statistically significant. CONCLUSIONS: Prepackaged all-inclusive kits for novices improved the procedure quality and saved staff time resources in a controlled simulation environment. Future studies are needed to address whether central line kits also improve patient safety in hospital settings

Fruit and vegetable consumption and lung cancer risk: updated information from the European Prospective Investigation into Cancer and Nutrition (EPIC)

The association of fruit and vegetable consumption and lung cancer incidence was evaluated using the most recent data from the European Prospective Investigation into Cancer and Nutrition (EPIC), applying a refined statistical approach (calibration) to account for measurement error potentially introduced by using food frequency questionnaire data. Between 1992 and 2000, detailed information on diet and life-style of 478,590 individuals participating in EPIC was collected. During a median follow-up of 6.4 years, 1,126 lung cancer cases were observed. Multivariate Cox proportional hazard models were applied for statistical evaluation. In the whole study population, fruit consumption was significantly inversely associated with lung cancer risk while no association was found for vegetable consumption. In current smokers, however, lung cancer risk significantly decreased with higher vegetable consumption; this association became more pronounced after calibration, the hazard ratio (HR) being 0.78 (95% CI 0.620.98) per 100 g increase in daily vegetable consumption. In comparison, the HR per 100 g fruit was 0.92 (0.85-0.99) in the entire cohort and 0.90 (0.81-0.99) in smokers. Exclusion of cases diagnosed during the first 2 years of follow-up strengthened these associations, the HR being 0.71 (0.55-0.94) for vegetables (smokers) and 0.86 (0.78-0.95) for fruit (entire cohort). Cancer incidence decreased with higher consumption of apples and pears (entire cohort) as well as root vegetables (smokers). In addition to an overall inverse association with fruit intake, the results of this evaluation add evidence for a significant inverse association of vegetable consumption and lung cancer incidence in smokers. (C) 2007 Wiley-Liss, Inc

"Best practice" skills lab training vs. a "see one, do one" approach in undergraduate medical education: an RCT on students' long-term ability to perform procedural clinical skills.

BACKGROUND: Benefits of skills lab training are widely accepted, but there is sparse research on its long-term effectiveness. We therefore conducted a prospective, randomised controlled-trial to investigate whether in a simulated setting students trained according to a "best practice" model (BPSL) perform two skills of different complexity (nasogastral tube insertion, NGT; intravenous cannulation, IVC) better than students trained with a traditional "see one, do one" teaching approach (TRAD), at follow-up of 3 or 6 months. METHODOLOGY AND PRINCIPAL FINDINGS: 94 first-year medical students were randomly assigned to one of four groups: BPSL training or TRAD teaching with follow-up at 3 (3M) or 6 (6M) months. BPSL included structured feedback, practice on manikins, and Peyton's "Four-Step-Approach", while TRAD was only based on the "see one - do one" principle. At follow-up, manikins were used to assess students' performance by two independent blinded video-assessors using binary checklists and a single-item global assessment scale. BPSL students scored significantly higher immediately after training (NGT: BPSL3M 94.8%±0.2 and BPSL6M 95.4%±0.3 percentage of maximal score ± SEM; TRAD3M 86.1%±0.5 and TRAD6M 84.7%±0.4. IVC: BPSL3M 86.4%±0.5 and BPSL6M 88.0%±0.5; TRAD3M 73.2%±0.7 and TRAD6M 72.5%±0.7) and lost significantly less of their performance ability at each follow-up (NGT: BPSL3M 86.3%±0.3 and TRAD3M 70.3%±0.6; BPSL6M 89.0%±0.3 and TRAD6M 65.4%±0.6; IVC: BPSL3M 79.5%±0.5 and TRAD3M 56.5%±0.5; BPSL6M 73.2%±0.4 and TRAD6M 51.5%±0.8). In addition, BPSL students were more often rated clinically competent at all assessment times. The superiority at assessment after training was higher for the more complex skill (IVC), whereas NGT with its lower complexity profited more with regard to long-term retention. CONCLUSIONS: This study shows that within a simulated setting BPSL is significantly more effective than TRAD for skills of different complexity assessed immediately after training and at follow-up. The advantages of BPSL training are seen especially in long-term retention

Effectiveness of IV Cannulation Skills Laboratory Training and Its Transfer into Clinical Practice: A Randomized, Controlled Trial

<div><h3>Background</h3><p>The effectiveness of skills laboratory training is widely recognized. Yet, the transfer of procedural skills acquired in skills laboratories into clinical practice has rarely been investigated. We conducted a prospective, randomised, double-blind, controlled trial to evaluate, if students having trained intravenous (IV) cannulation in a skills laboratory are rated as more professional regarding technical and communication skills compared to students who underwent bedside teaching when assessed objectively by independent video assessors and subjectively by patients.</p> <h3>Methodology and Principal Findings</h3><p>84 volunteer first-year medical students were randomly assigned to one of two groups. Three drop-outs occurred. The intervention group (IG; <em>n</em> = 41) trained IV cannulation in a skills laboratory receiving instruction after Peyton's ‘Four-Step Approach’. The control group (CG; <em>n</em> = 40) received a bedside teaching session with volunteer students acting as patients. Afterwards, performance of IV cannulation of both groups in a clinical setting with students acting as patients was video-recorded. Two independent, blinded video assessors scored students' performance using binary checklists (BC) and the Integrated Procedural Protocol Instrument (IPPI). Patients assessed students' performance with the Communication Assessment Tool (CAT) and a modified IPPI. IG required significantly shorter time needed for the performance on a patient (IG: 595.4 SD(188.1)s; CG: 692.7 SD(247.8)s; 95%CI 23.5 s to 45.1 s; p = 0.049) and completed significantly more single steps of the procedure correctly (IG: 64% SD(14) for BC items; CG: 53% SD(18); 95%CI 10.25% to 11.75%; p = 0.004). IG also scored significantly better on IPPI ratings (median: IG: 3.1; CG: 3.6; p = 0.015;). Rated by patients, students' performance and patient-physician communication did not significantly differ between groups.</p> <h3>Conclusions</h3><p>Transfer of IV cannulation-related skills acquired in a skills laboratory is superior to bedside teaching when rated by independent video raters by means of IPPI and BC. It enables students to perform IV cannulation more professionally on volunteer students acting as patients.</p> </div

Study design.

<p>* Kolb = Kolb Learning Style Inventory; JSPE = Jefferson Scale of Physician Empathy; GSE = General Self-Efficacy; SE = IV cannulation related Self-Efficacy. Post-interventional Evaluation = Evaluation of teaching model acceptance. IPPI = Integrated Procedural Protocol Instrument; CAT = Communication Assessment Tool; BC = Binary Checklist. Figure modified from the CONSORT 2010 flow diagram templates <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032831#pone.0032831-Moher1" target="_blank">[50]</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0032831#pone.0032831-Moher2" target="_blank">[51]</a>.</p

Baseline data.

<p>LSI = Kolb Learning Style Inventory; JSPE = Jefferson Scale of Physician Empathy; GSE = General Self-Efficacy. Data are means (SD) or numbers (%) or medians. P-values were calculated using students t-test for age, chi-quadrat test for gender, preceeding health care related or medical profession other than paramedic or nurse (i.e. physiotherapy, dental assistant, etc.), civil service and nursing electives. Mann-Whitney U-Tests for LSI, JSPE, GSE and Pre-Interventional IV cannulation-related Self-Efficacy.</p

Loss of skills level expressed as percentage of points on the corresponding binary checklist (NGT or IVC) at 3 (Figure 2A) and 6 months (Figure 2B) after initial training, respectively (error bars refer to SEM).

<p>NGT = nasogastral tube insertion, IVC = intravenous cannulation, BSPL = Best Practice Skills Lab Training, TRAD = Traditional “see one, do one” teaching.</p

Results of the patient-ratings of students' IV cannulation skills.

<p>CAT = Communication Assessment Tool (12 items, Likert-scale rating ranging from 1 = “very good” to 6 = “unsatisfactory”); IPPI = Integrated Procedural Performance Instrument (11 items, Likert-scale rating ranging from 1 = “very good” to 6 = “unsatisfactory”); median; P-values were calculated using Mann-Whitney U-Test results.</p

Results of the video ratings of students' IV cannulation skills.

<p>BC = binary checklist (percent of correctly demonstrated procedural single steps); IPPI = Integrated Procedural Performance Instrument (11 items, Likert-scale rating ranging from 1 = very good to 6 = unsatisfactory); SD = standard deviation; SEM_D = standard error of the mean difference; P-values are calculated with students T-test results for BC and Mann-Whitney U-Test results for IPPI.</p

Study design and randomisation process.

<p>BPSL = “best practice” skills lab, TRAD = “see one, do one”, OSCE = Objective Structured Clinical Examination, 3M = follow-up after 3 months, 6M = follow up after 6 months * = video material not useable.</p