Abstract
Healthcare providers demonstrate wide variability in their skill at performing medical procedures safely. Objective measures of clinical skills are rarely used in making high-stakes personnel decisions. Hospitals and other privileging, licensing, and credentialing bodies use aggregate number systems to determine if individual healthcare providers are safe and ready to perform clinical procedures. However, many studies show that neither clinical experience (number of procedures performed) nor provider self-confidence correlate with actual procedural skill. Simulation-based mastery learning (SBML) can be used to ensure that individual healthcare providers are competent to perform invasive procedures. In this chapter, we discuss how SBML has been used to boost bedside procedural skills. Specifically, we describe how SBML curricula were developed using the Thomas and Kern framework for bedside procedural skills including thoracentesis, paracentesis, central venous catheter (CVC) insertion, and CVC maintenance. We also review how translational science outcomes are used to provide validity evidence about the effectiveness of these curricula.
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Appendices
Appendix 13.1: Thoracentesis Checklist
Thoracentesis
Skill key: A = done correctly B = done incorrectly/not done
Informed consent obtained Benefits Risks Permission given | A | B |
Call “time-out” | A | B |
Wash hands | A | B |
Identify the landmarks based on ultrasound (identify fluid, the lung, and the diaphragm) | A | B |
Mark the site using ultrasound | A | B |
Clean area with chlorhexidine solution | A | B |
Put on sterile gloves | A | B |
Drape the area | A | B |
Set up the kit using the catheter/tubing/stop cock system (making sure the flow is from needle to syringe; this is the default position) | A | B |
Use 1% lidocaine to anesthetize the skin area above the rib (wheal) | A | B |
Using lidocaine, anesthetize to the bone and pleura with a longer needle | A | B |
Aspirate pleural fluid with this needle | A | B |
Using the thoracentesis needle (catheter/needle complex), enter the skin above the rib while aspirating (two hands) | A | B |
Once the catheter is about to enter the skin, nick the skin with a scalpel at the entry site, and continue to advance the catheter/needle unit | A | B |
Identify that the catheter and needle have entered the pleural space. White changes to red to white again, and aspirate fluid | A | B |
Advance the catheter over the needle until it is in the pleural space, and withdraw the needle syringe unit | A | B |
Turn the stop cock to direct the flow from the catheter in the pleural space to the tubing | A | B |
Connect the tubing to syringe, and using the “push and pull method,” aspirate fluid into the bag | A | B |
Aspirate no more than 1.5 L of fluid (1 L is acceptable) unless no symptoms (ask how much are you removing?) | ||
Withdraw catheter/syringe while patient exhales (resident must communicate) | A | B |
Place dressing | A | B |
Demonstrate knowledge as to whether to order a chest x-ray | A | B |
Blood cx inoculated at the bedside (can verbalize) | ||
Transfer fluid into appropriate vials, and send for appropriate studies: LDH, protein, cell count, gram stain and culture, cytology, and pH | A | B |
Communicate with the nurse about procedure completion | A | B |
Maintain sterile technique | A | B |
Appendix 13.2: Central Line Insertion Checklist for Internal Jugular (IJ) and Subclavian (SC) Veins
Central Line Insertion (IJ)
Skill key: A = done correctly B = done incorrectly/not done
Informed consent obtained Benefits (medicines, fluids) Risks (infection, bleeding, pneumothorax) Consent given | A | B |
Call “time-out,” and site mark if appropriate (must be done before any needles enter the skin) | A | B |
Wash hands | A | B |
Place the patient in slight Trendelenburg position | A | B |
Area is cleaned with chlorhexidine (30 seconds, scrub back forth) If scrubbing back and forth can ask “how long do you need to scrub?” | A | B |
Don sterile gown, gloves, hat, and mask | A | B |
Area is draped in usual sterile fashion (must be full-body drape) | A | B |
The US probe is properly set up and draped, and sonographic gel is used on inside and outside of sheath (more important inside) | A | B |
Test each port, and flush the lines with sterile saline | A | B |
Clamp each port (okay to keep distal port open), or use caps (caps must be flushed) | A | B |
Keep distal port open to accommodate guidewire | A | B |
The vein is localized using anatomical landmarks with the ultrasound machine | A | B |
The skin is anesthetized with 1% lidocaine in a small wheal | A | B |
The deeper structures are anesthetized | A | B |
Using the large-needle (or catheter) syringe complex, cannulate the vein while aspirating with proper US technique | A | B |
Remove the syringe from the needle, or advance the catheter into the vein (must be hubbed) removing both the syringe and needle | A | B |
Advance the guidewire into the vein no more than about 15 cm (range 10–20 cm) | A | B |
Make sure to nick the skin to advance the dilator (scalpel) | A | B |
Advance the dilator over the guidewire, and dilate the tissue tract | A | B |
Advance the triple lumen over the wire, holding the guidewire steady as moving forward with the catheter | A | B |
Never let go of the guidewire | A | B |
Once the line is in place, remove the guidewire in its entirety | A | B |
Advance the line to approx. 14–16 cm for right side and 16–18 cm for left side | A | B |
Ensure there is blood flow/flush each port (must aspirate before flushing). Place caps here if not done earlier, and flush through | A | B |
Secure the line in place using the connector correctly (suturing should be verbalized only) | A | B |
Place sterile dressing | A | B |
Get a chest x-ray to confirm location State “the cxr shows no ptx, and you are at the RA SVC junction (if proper depth of insertion)” | A | B |
Notify nurse that line is okay to use | A | B |
Maintain sterile technique | A | B |
Central Line Placement (Subclavian)
Skill key: A = done correctly B = done incorrectly/not done. **Only one step in italics is used depending on if ultrasound is used
Informed consent obtained Benefits (medicines, fluids) Risks (infection, bleeding, pneumothorax) Consent given | A | B |
Call “time-out,” and site mark if appropriate (must be done before any needles enter the skin) | A | B |
Wash hands | A | B |
Place the patient in slight Trendelenburg position | A | B |
Area is cleaned with chlorhexidine (30 seconds, scrub back forth) If scrubbing back and forth, can ask “how long do you need to scrub?” | A | B |
Don sterile gown, gloves, hat, and mask | A | B |
Area is draped in usual sterile fashion (must be full-body drape) | A | B |
**The US probe is properly set up and draped, and sonographic gel is used on both sides of the sheath (must do if using ultrasound) | A | B |
Test each port, and flush the lines with sterile saline | A | B |
Clamp each port (okay to leave distal port open), or use caps (caps must be flushed) | A | B |
Keep distal port open to accommodate guidewire | A | B |
The vein is localized using ultrasound machine or anatomical landmarks verbalized. “I am going 1 cm under the clavicle at 1/3:2/3 the way” Okay to ask “how did you determine the site of needle entry?” | A | B |
The skin is anesthetized with 1% lidocaine in a small wheal | A | B |
The deeper structures are anesthetized using a larger needle (must numb the periosteum of the clavicle) | A | B |
Using the large-needle (or catheter) syringe complex, cannulate the vein while aspirating (optional, confirmed by US) | A | B |
**If US was not used then expected to state or demonstrate they must direct the needle to the sternal notch (must verbalize) (if US was used, may omit) Okay to ask “what direction is your needle pointed, toward what anatomic structure?” | A | B |
Remove the syringe from the needle, or advance the catheter into the vein (must be hubbed) removing both the syringe and needle | A | B |
Advance the guidewire into the vein no more than 15 cm (range 10–20 cm) | A | B |
Make sure to nick the skin to advance the dilator (scalpel) | A | B |
Advance the dilator over the guidewire, and dilate the tissue tract | A | B |
Advance the triple lumen over the wire, holding the guidewire steady as moving forward with the catheter | A | B |
Never let go of the guidewire | A | B |
Once the line is in place, remove the guidewire in its entirety | A | B |
Advance the line to approx. 14–16 cm for right side and 16–18 cm for left side | A | B |
Ensure there is blood flow/flush each port (must aspirate before flushing). Place caps here if not done earlier, and flush through | A | B |
Secure the line in place using the connector correctly (suturing should be verbalized only) | A | B |
Place sterile dressing | A | B |
Get a chest x-ray to confirm location State “the cxr shows no ptx, and you are at the RA SVC junction (if proper depth of insertion)” | A | B |
Notify nurse that line is okay to use | A | B |
Maintain sterile technique | A | B |
Appendix 13.3: Central Line Maintenance Checklists
Central Line Maintenance: PICC and CVC
Skill key: 1 = done correctly 0 = done incorrectly/not done
Task | Correct | Incorrect |
|---|---|---|
Medication administration (IV push or piggyback) | ||
Maintain aseptic technique and standard precautions during the procedure | 1 | 0 |
Perform hand hygiene | 1 | 0 |
Don gloves | 1 | 0 |
Scrub injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds (or for units using 70% isopropyl alcohol-impregnated port protectors: Remove and discard port protector) | 1 | 0 |
Attach a pre-filled NS syringe to the injection cap | 1 | 0 |
If present, open catheter clamp | 1 | 0 |
Slowly inject 10 mL NS flush solution | 1 | 0 |
Scrub injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds | 1 | 0 |
Administer IV push medication (if IV piggyback, luer lock the secondary infusion pump tubing to the cleansed port. Procedure ends here for IV piggyback medications) | 1 | 0 |
Scrub injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds | 1 | 0 |
Flush with 10 mL NS (as described above) | 1 | 0 |
Detach syringe first to activate the positive pressure valve; then clamp catheter | 1 | 0 |
For units using 70% isopropyl alcohol-impregnated port protectors, apply port protectors to all CVAD access ports that do not have active infusions | 1 | 0 |
Tubing change: connection to injection cap or hub | ||
Maintain aseptic technique and standard precautions during the procedure | 1 | 0 |
Perform hand hygiene | 1 | 0 |
Don gloves | 1 | 0 |
Close the catheter clamp | 1 | 0 |
Disconnect old tubing and discard | 1 | 0 |
Scrub the CVAD injection cap with CHG solution for 15 seconds, place on sterile 4 × 4 gauze, and allow to dry for at least 15 seconds | 1 | 0 |
Connect new infusion tubing to CVAD injection cap/hub. If connecting to the hub, don a mask before disconnection | 1 | 0 |
Open catheter clamp | 1 | 0 |
Restart infusion pump(s) | 1 | 0 |
Apply “date to be changed” label to tubing | 1 | 0 |
For units using 70% isopropyl alcohol-impregnated port protectors, apply port protectors to all CVAD access ports that do not have active infusions | 1 | 0 |
Injection cap change | Correct | Incorrect |
|---|---|---|
Maintain aseptic technique and standard precautions during the procedure | 1 | 0 |
Perform hand hygiene | 1 | 0 |
Don mask and non-sterile gloves | 1 | 0 |
Mask the patient if the patient is able to tolerate; otherwise instruct the patient to turn his or her head away from the procedure | 1 | 0 |
Without removing protective covering from the new injection cap, prime the injection cap with normal saline using aseptic technique. The covering is a flush-through covering | 1 | 0 |
Close the catheter clamp on CVAD | 1 | 0 |
Remove and dispose of the old injection cap | 1 | 0 |
Scrub the CVAD hub with CHG solution for 15 seconds, place on sterile 4 × 4 gauze, and allow to dry for at least 15 seconds | 1 | 0 |
Connect the new injection cap | 1 | 0 |
Open catheter clamp on CVAD | 1 | 0 |
Slowly inject NS flush solution | 1 | 0 |
Detach syringe first to activate the positive pressure valve; then close clamp on catheter | 1 | 0 |
For units using 70% isopropyl alcohol-impregnated port protectors, apply port protectors to all CVAD access ports that do not have active infusions | 1 | 0 |
Indirect blood draw through injection cap | Correct | Incorrect |
|---|---|---|
Maintain aseptic technique and standard precautions during the procedure | 1 | 0 |
Perform hand hygiene | 1 | 0 |
Don non-sterile gloves | 1 | 0 |
Stop all infusion(s) | 1 | 0 |
Clamp all CVAD lumens | 1 | 0 |
Scrub injection cap for 15 seconds with CHG solution, place on sterile 4 x 4 gauze, and allow to dry at least 15 seconds | 1 | 0 |
Attach the first of two 10 mL NS syringes to the CVAD cap; slowly inject NS | 1 | 0 |
Remove syringe | 1 | 0 |
Scrub the injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds | 1 | 0 |
Attach second of two 10 mL NS syringes to the injection cap; slowly inject NS | 1 | 0 |
Using the same syringe, aspirate 10 mL of blood for waste | 1 | 0 |
Remove 10 mL waste syringe and discard | 1 | 0 |
Scrub the injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds | 1 | 0 |
Attach 10 or 20 mL syringe | 1 | 0 |
Aspirate a minimum of 10 mL but no more than 20 mL of blood | 1 | 0 |
Remove syringe, and place on sterile 4 × 4 gauze | 1 | 0 |
Scrub the injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds | 1 | 0 |
Attach the first of 2 mL NS syringes to injection cap of catheter | 1 | 0 |
Slowly inject NS; detach syringe | 1 | 0 |
Scrub the injection cap with CHG solution for 15 seconds, and allow to dry for at least 15 seconds | 1 | 0 |
Attach the second 10 mL NS syringe to the injection cap; slowly inject NS | 1 | 0 |
Detach syringe first to activate the positive pressure valve; then clamp catheter if not being used for infusion(s) | 1 | 0 |
Unclamp CVAD lumen(s) being used for infusion(s) | 1 | 0 |
Restart infusion pump(s) | 1 | 0 |
For units using 70% isopropyl alcohol-impregnated port protectors, apply port protectors to all CVAD access ports that do not have active infusions | 1 | 0 |
Dressing change | Correct | Incorrect |
|---|---|---|
Maintain aseptic technique and standard precautions during the procedure | 1 | 0 |
Perform hand hygiene | 1 | 0 |
Don non-sterile gloves | 1 | 0 |
Open the central line dressing kit maintaining sterility at all times. Add additional sterile supplies needed for procedure to sterile field prior to beginning the procedure | 1 | 0 |
Don mask found in the kit | 1 | 0 |
Mask the patient if the patient is able to tolerate a mask; otherwise instruct the patient to turn his or her head away during the procedure | 1 | 0 |
Remove the entire dressing; loosen the edges without touching the area under the dressing | 1 | 0 |
Remove non-sterile gloves, and discard | 1 | 0 |
Perform hand hygiene | 1 | 0 |
Don sterile gloves | 1 | 0 |
Remove securing device if present (must be done with sterile gloves) | 1 | 0 |
Cleanse catheter insertion site using CHG solution. Scrub the skin with a back and forth motion for 30 seconds, covering a 4 inch surface | 1 | 0 |
Allow the CHG solution to dry for at least 30 seconds | 1 | 0 |
If applicable, attach a securing device to the PICC line | 1 | 0 |
If sutures are loose or no longer intact, secure catheter with sterile tape strips to prevent catheter migration | 1 | 0 |
Optional: Apply tincture of benzoin to the perimeter of the dressing area – avoid insertion site – to increase adherence of dressing to the skin, if necessary. Allow to dry | 1 | 0 |
When site is completely dry, apply the TSM dressing. Ensure occlusiveness (if the dressing is not occlusive, a new dressing must be reapplied. Do not attempt to secure TSM dressing with tape) | 1 | 0 |
Apply date label with date of change to dressing and initial. TSM dressings are changed 24 hours post CVAD insertion and every 6 days (to coincide with IV tubing changes), whenever the dressing is no longer occlusive or there is blood, other drainage, or signs of inflammation present | 1 | 0 |
Appendix 13.4: Paracentesis Checklist
Paracentesis
Skill key: A = done correctly B = done incorrectly/not done
Informed consent obtained Benefits (relief, diagnosis) Risks (infection, bleeding) Consent given | A | B |
Call “time-out,” and site mark if appropriate | A | B |
Wash hands | A | B |
Identify the landmarks based on percussion or ultrasound | A | B |
Clean area with sterilizing solution (chlorhexidine) | A | B |
Put on sterile gloves | A | B |
Drape the area | A | B |
Set up the kit | A | B |
Use lidocaine to anesthetize the skin (wheal) | A | B |
Using lidocaine, anesthetize deeper | A | B |
Use Z technique, lift and drop, or angle | A | B |
Using the Safe-T-Centesis needle (catheter/needle complex), enter the skin while aspirating (one hand holding the needle plush on the chest wall and the other on the syringe) | A | B |
Once the catheter is about to enter the skin, nick the skin with a scalpel at the entry site, and continue to advance the catheter/needle unit while aspirating | A | B |
Identify that the catheter and needle have entered the fluid space. White changes to red to white again, and aspirate fluid | A | B |
Advance the catheter over the needle until it is in the space, and withdraw the needle syringe unit (care not to advance the needle) | A | B |
Turn the stop cock to direct the flow from the catheter into the tubing | A | B |
Connect the tubing to a 1 L Vacutainer or the apparatus connected to the aspirating syringe, and inject fluid into the bag | A | B |
Will you give the patient albumin and how much? | A | B |
Withdraw catheter/syringe | A | B |
Place dressing | A | B |
Position the patient with area up | A | B |
Blood cx inoculated at the bedside (can verbalize) | A | B |
What studies need to be sent? Must say cell count, gram stain and culture, albumin | A | B |
Notify the nurse the procedure is done, and give post-procedure orders | A | B |
Sterile technique is maintained | A | B |
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Barsuk, J.H., Cohen, E.R., Wayne, D.B. (2020). Mastery Learning of Bedside Procedural Skills. In: McGaghie, W., Barsuk, J., Wayne, D. (eds) Comprehensive Healthcare Simulation: Mastery Learning in Health Professions Education. Comprehensive Healthcare Simulation. Springer, Cham. https://doi.org/10.1007/978-3-030-34811-3_13
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