Novosel Tj

The impact of central line simulation before the ICU experience

BACKGROUND This study was designed to evaluate whether resident performance of placing central lines improved after simulation training on newly available partial-task simulators. METHODS This study was designed as a prospective, randomized controlled trial of standard training versus simulated training using CentralLine Man (SimuLab, Seattle, WA, USA). After receiving a lecture on central line placement, all junior residents on the trauma rotation were randomized on a monthly alternating schedule. Equivalency of groups was determined with a self-reported survey. All lines placed by the participants were monitored, and data were collected on performance and complications. RESULTS The 2 groups (n = 34; 21 standard and 13 simulated) were equivalent at baseline. The simulated training group had a significantly higher level of comfort and ability than the standard training group. The simulated group outperformed the standard group on 12 of the 15 specific variables monitored, although this did not reach statistical significance. There were significantly more complications in the standard group. CONCLUSIONS Simulation for central line placement using a partial-task simulator does positively impact resident performance.

Impact of a monitored program of care on incidence of ventilator-associated pneumonia: results of a longterm performance-improvement project.

BACKGROUND Ventilator-associated pneumonia (VAP) remains a major source of morbidity, mortality, and expense in the ICU despite therapies directed against it. STUDY DESIGN A retrospective review of a prospectively developed performance-improvement project monitoring the incidence of VAP in two adjacent ICUs was conducted. In response to an excessive VAP rate, weekly multidisciplinary team meetings were instituted to review data, develop care protocols, and modify care routines. Protocol compliance was monitored daily and feedback provided weekly to the care teams. VAP rates were determined by the institutional Infection Control Committee and reviewed monthly with the ICU multidisciplinary team. Duration of the investigational period was 10 years. RESULTS A standardized ventilator-weaning protocol was instituted with confirmed 95% use. Additional modifications of care, such as patient positioning, use of specific endotracheal tubes to minimize aspiration of supraglottic secretions, an oral-care regimen, and aggressive antibiotic stewardship were standardized, with a compliance rate >90%. VAP rates dropped from 12.8 per 1,000 patient-days in 1998 to 1.1 in 2007 in the burn trauma ICU and from 21.2 to <1 in the neurotrauma ICU in the same time frame. Also, mean ventilator length of stay decreased from 6 days to 4.2 and from 5.8 days to 4.75 simultaneously in the respective ICUs. Such performance improvement has been sustained since implementation of the program. CONCLUSION A systematic, monitored program of standardized care protocols can markedly reduce VAP rate in the ICU.

Thoracic ultrasound can predict safe removal of thoracostomy tubes.

BACKGROUND Chest x-rays (CXRs) have been the mainstay for the management of thoracostomy tubes (TTs), but reports that ultrasound (US) may be more sensitive for detection of pneumothorax (PTX) continue to increase. The objective of this study was to determine if US is safe and effective for the detection of PTX following TT removal. METHODS This was a retrospectively reviewed, prospective process improvement project involving patients who had a TT managed by the surgical team. Bedside US was performed by experienced surgeon sonographers before and after TT removal. Initially, a CXR was obtained before and after TT removal, with sonographers blinded to CXR findings. Subsequently, routine CXR was no longer obtained, and TT removal was determined by US. RESULTS One hundred twenty-nine TTs were placed during the study. Initially, water seal and postpull US were performed on 49 TTs, with 6 tubes having only postpull imaging. US was able to detect all significant PTXs seen on CXR but identified one false-positive. Subsequently, 74 TTs had US imaging on water seal and after pull. Water seal US allowed the safe removal of 70% of the TTs. Twenty patients had no slide on water seal US and required follow-up CXR. Most importantly, US had a 100% negative predictive value for PTX during TT removal. CONCLUSION US is safe and effective for the rapid diagnosis of PTX. This has allowed the discontinuation of routine CXR for the evaluation of PTX during TT removal for patients with adequate lung slide seen on thoracic US lung windows. LEVEL OF EVIDENCE Diagnostic test, level II. Therapeutic study, level IV.