53 The Impact of an Ultrasound Guided-Central Venous Access Training Course on Central Line-Associated Blood Stream Infection Rate

Abstract

Prior research has examined methods and processes for the teaching of ultrasound-guided central venous access (USGVA). None have assessed the impact of this training on the inserter’s central line-associated blood stream infection (CLABSI) rate. To address this limitation, we designed and conducted a standardized training course and a performance-based competency examination for all residents at a single institution and assessed the impact on the resident CLABSI rate. 222 residents (PGY 1-9), all of whom had prior department approval for independent central line placement participated in a training course composed of asynchronous and in-person didactic training on aseptic techniques, complications, principles of ultrasound guidance, and institutional standards for central venous access (CVA). A competency assessment was then completed by each resident using a novel gel-based cadaver model. The participant was graded with a standardized grading rubric by course faculty and assigned a pass or fail grade. CLABSI data pre and post training was collected from institution epidemiological monitoring. Only central venous lines placed by residents in adult patients and CLABSI occurring within 7 days of insertion were included in the analysis. Excluded from the analysis were central venous lines in individuals under 18 and those placed in an emergency (not-certified lines). CLABSI rates were calculated in per thousand central line days for each quarter using hospital-wide data. All statistical analyses were conducted at significance level of 0.05 using SAS 9.4. The nonparametric Wilcoxon-Mann-Whitney test was used to examine the median differences of CLABSI before and after intervention and including or excluding residents who failed the assessment. 222 residents completed the training and took the performance-based assessment. 32% (n=72) did not pass the USGVA competency assessment. Four-quarters of CLASBI data before the training and five-quarters after were used to determine the CLABSI rate. The median resident CLABSI rate before training was 0.3755/1000 days. The median CLABSI rate after training was 0.1448/1000 days (p value 0.2857). These values included all resident regardless of assessment outcome. When residents who failed the competency assessment were removed from the post training analysis the CLABSI rate was 0.00 (p value 0.0238). Our analysis showed training alone did not have a significant impact on the CLABSI rate although 90% of the participants felt the training “somewhat” or “significantly” improved both knowledge and skill. However, passing or failing the assessment did have a significant effect on the resident CLASBI rate. There would have been a significant decrease in CLABSI’s in the post-training time period if residents who failed to successfully completed the assessment had been prevented from placing central lines. These results demonstrated that standardized competency performance-based testing was a better discriminator of skill performance than education alone or departmental discretion of competency. Although passing the assessment at this time was not a prerequisite for independent USGVA, these results and ongoing monitoring have prompted by hospital administration to revise the certification for independent USGVA making passing the clinical assessment a part of the process.