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Background: Ventricular assist device simulation-based mastery learning (SBML) results in better patient and caregiver self-care skills compared with usual training., Objective: The aim of this study was to evaluate the effect of SBML on driveline exit site infections., Methods: We compared the probability of remaining infection free at 3 and 12 months between patients randomized to SBML or usual training., Results: The SBML-training group had no infections at 3 months and 2 infections at 12 months, yielding a Kaplan-Meier estimate of the probability of remaining infection free of 0.857 (95% confidence interval [CI], 0.692-1.00) at 12 months. The usual-training group had 6 infections at 3 months with no additional infections by 12 months. Kaplan-Meier estimates of remaining infection free at 3 and 12 months were 0.878 (95% CI, 0.758-1.00) and 0.748 (95% CI, 0.591-0.946), respectively. Time-to-infection distributions for SBML versus usual training showed a difference in 12-month infection rates of 0.109 (P = .07)., Conclusions: Ventricular assist device self-care SBML resulted in fewer 12-month infections., Competing Interests: Dr Wilcox receives consulting honoraria from Boehringer Ingelheim and Medtronic and serves on the scientific advisory board for Cytokinetics. The other authors have no relevant conflicts of interest to report., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients., Methods: We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period., Results: One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period., Conclusions: A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Resident physicians are expected to acquire competence at central venous catheter (CVC) insertion to a mastery standard. Valid competence decisions about resident physicians' CVC performance rely on reliable data and rigorous achievement standards. This study used data from 3 CVC simulation-based mastery learning studies involving internal medicine (IM) and emergency medicine (EM) residents to address 2 questions: What is the effectiveness of a CVC mastery learning education intervention? Are minimum passing standards (MPSs) set by faculty supported by item response theory (IRT) analyses?, Methods: Pretraining and posttraining skills checklist data were drawn from 3 simulation-based mastery learning research reports about CVC internal jugular (IJ) and subclavian (SC) insertion skill acquisition. Residents were required to meet or exceed a posttest skills MPS. Generalized linear mixed effect models compared checklist performance from pre to postintervention. Minimum passing standards were determined by Angoff and Hofstee standard setting methods. Item response theory models were used for cut-score evaluation., Results: Internal medicine and EM residents improved significantly on every IJ and SC checklist item after mastery learning. Item response theory analyses support the IJ and SC MPSs., Conclusions: Mastery learning is an effective education intervention to achieve clinical skill acquisition among IM and EM residents. Item response theory analyses reveal desirable measurement properties for the MPSs previously set by expert faculty panels. Item response theory analysis is useful for evaluating standards for mastery learning interventions. The CVC mastery learning curriculum, reliable outcome data, and high achievement standards together contribute to reaching valid decisions about the competence of resident physicians to perform the clinical procedure., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 Society for Simulation in Healthcare.)

Objectives: The aims of the study were to identify perceived barriers and facilitators to central venous catheter (CVC) insertion among healthcare providers and to understand the extent to which an existing Simulation-Based Mastery Learning (SBML) program may address barriers and leverage facilitators., Methods: Providers participating in a CVC insertion SBML train-the-trainer program, in addition to intensive care unit nurse managers, were purposively sampled from Veterans Administration Medical Centers located in geographically diverse areas. We conducted semistructured interviews to assess perceptions of barriers and facilitators to CVC insertion. Deidentified transcripts were analyzed using a grounded theory approach and the constant comparative method. We subsequently mapped identified barriers and facilitators to our SBML curriculum to determine whether or not the curriculum addresses these factors., Results: We interviewed 28 providers at six Veterans Administration Medical Centers, identifying the following five overarching factors of perceived barriers to CVC insertion: (1) equipment, (2) personnel/staff, (3) setting or organizational context, (4) patient or provider, and (5) time-related barriers. Three overarching factors of facilitators emerged: (1) equipment, (2) personnel, and (3) setting or organizational context facilitators. The SBML curriculum seems to address most identified barriers, while leveraging many facilitators; building on the commonly identified facilitator of nursing staff contribution by expanding the curriculum to explicitly include nurse involvement could improve team efficiency and organizational culture of safety., Conclusions: Many identified facilitators (e.g., ability to use ultrasound, personnel confidence/competence) were also identified as barriers. Evidence-based SBML programs have the potential to amplify these facilitators while addressing the barriers by providing an opportunity to practice and master CVC insertion skills., Competing Interests: J.H.B. and D.B.W. received consulting fees from MERCI. J.H.B., D.B.W. and E.R.C. received royalties for the central venous catheter insertion simulation-based mastery learning curriculum from Northwestern University. The remaining authors disclose no conflict of interest., (Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patients who undergo ventricular assist device (VAD) implantation and their caregivers must rapidly learn a significant amount of self-care skills and knowledge., Objective: The aim of this study was to explore patient, caregiver, VAD coordinator, and physician perspectives and perceptions of existing VAD self-care training to inform development of a simulation-based mastery learning (SBML) curriculum to teach patients and caregivers VAD self-care skills and knowledge., Methods: We conducted semistructured, in-person interviews with patients with a VAD, their caregivers, VAD coordinators, and physicians (cardiac surgeons, an infectious disease physician, and advanced heart failure cardiologists). We used a 2-cycle team-based iterative inductive approach to coding and analysis., Results: We interviewed 16 patients, 12 caregivers, 7 VAD coordinators, and 11 physicians. Seven major themes were derived from the interviews including (1) identification of critical curricular content, (2) need for standardization and assessment, (3) training modalities, (4) benefits of repetition, (5) piercing it all together, (6) need for refresher training, and (7) provision of training before implant., Conclusions: Findings from this study suggest that SBML is a natural fit for the high-risk tasks needed to save VAD self-care. The 7 unique training-related themes derived from the qualitative data informed the design and development of a VAD SBML self-care curriculum.

Background: No recognized standards exist for teaching patients and their caregivers ventricular assist device (VAD) self-care skills. We compared the effectiveness of a VAD simulation-based mastery learning (SBML) self-care training curriculum with usual VAD self-care training., Methods and Results: VAD patients and their caregivers were randomized to SBML or usual training during their implant hospitalization. The SBML group completed a pretest on 3 VAD self-care skills (controller, power source, and dressing change), then viewed videos and participated in deliberate practice on a simulator. SBML participants took a posttest and were required to meet or exceed a minimum passing standard for each of the skills. The usual training group completed the existing institutional VAD self-care teaching protocol. Before hospital discharge, the SBML and usual training groups took the same 3 VAD self-care skills tests. We compared demographic and clinical information, self-confidence, total participant training time, and skills performance between groups. Forty participants completed the study in each group. There were no differences in demographic and clinical information, self-confidence, or training time between groups. More participants in the SBML group met the minimum passing standard compared with the usual training group for controller (37/40 [93%] versus 25/40 [63%]; P =0.001), power source (36/40 [90%] versus 9/40 [23%]; P <0.001), and dressing change skills (19/20 [95%] versus 0/20; P <0.001)., Conclusions: SBML provided superior VAD self-care skills learning outcomes compared with usual training. This study has important implications for patients due to the morbidity and mortality associated with improper VAD self-care., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03073005.

Objectives: Central venous catheter insertions may lead to preventable adverse events. Attending physicians' central venous catheter insertion skills are not assessed routinely. We aimed to compare attending physicians' simulated central venous catheterinsertion performance to published competency standards., Design: Prospective cohort study of attending physicians' simulated internal jugular and subclavian central venous catheter insertion skills versus a historical comparison group of residents who participated in simulation training., Setting: Fifty-eight Veterans Affairs Medical Centers from February 2014 to December 2014 during a 2-day simulation-based education curriculum and two academic medical centers in Chicago., Subjects: A total of 108 experienced attending physicians and 143 internal medicine and emergency medicine residents., Intervention: None., Measurements and Main Results: Using a previously published central venous catheter insertion skills checklist, we compared Veterans Affairs Medical Centers attending physicians' simulated central venous catheter insertion performance to the same simulated performance by internal medicine and emergency medicine residents from two academic centers. Attending physician performance was compared to residents' baseline and posttest (after simulation training) performance. Minimum passing scores were set previously by an expert panel. Attending physicians performed higher on the internal jugular (median, 75.86% items correct; interquartile range, 68.97-86.21) and subclavian (median, 83.00%; interquartile range, 59.00-86.21) assessments compared to residents' internal jugular (median, 37.04% items correct; interquartile range, 22.22-68.97) and subclavian (median, 33.33%; interquartile range, 0.00-70.37; both p < 0.001) baseline assessments. Overall simulated performance was poor because only 12 of 67 attending physicians (17.9%) met or exceeded the minimum passing score for internal jugular central venous catheter insertion and only 11 of 47 (23.4%) met or exceeded the minimum passing score for subclavian central venous catheter insertion. Resident posttest performance after simulation training was significantly higher than attending physician performance (internal jugular: median, 96%; interquartile range, 93.10-100.00; subclavian: median, 100%; interquartile range, 96.00-100.00; both p < 0.001)., Conclusions: This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Objective: To evaluate the association of a forceps simulation training curriculum for obstetrics residents on rates of severe perineal lacerations after forceps deliveries., Methods: This was a retrospective cohort study. We created a novel simulation curriculum for forceps-assisted vaginal delivery based on the best practices of local experts, and trained all residents beginning in 2013. We then retrospectively reviewed all forceps deliveries performed in the 2.5 years after initiation of the training and the 7.5 years before the training program. We identified patients who experienced a severe perineal laceration (third- or fourth-degree) and examined the relationship of resident training status and perineal laceration. Known risk factors for lacerations were identified and a multilevel multivariable model was created including these factors as well as resident training., Results: During the study period, we identified 6,058 forceps-assisted vaginal deliveries. We examined temporal trends in rates of forceps of severe perineal laceration. We identified a decrease in severe lacerations between 2005 and 2008, ending 5 years before the initiation of the training curriculum. These years were censored from the data, yielding a baseline observational period of 4,279 deliveries with no significant trend in laceration rate. Univariate analysis reveals a 22% reduction in severe perineal laceration (odds ratio [OR] 0.78; P=.005) among women delivered by residents who had completed forceps simulation training compared with women delivered by residents who had not. After adjusting for known maternal and delivery risk factors for perineal laceration, the magnitude of the reduction increased to 26% in the full data set model (OR 0.74; P=.002)., Conclusion: A forceps simulation curriculum for obstetrics residents was associated with a significant reduction in severe perineal lacerations.

Statement: Curriculum development in medical education should follow a planned, systematic approach fitted to the needs and conditions of a local institutional environment and its learners. This article describes the development and maintenance of a simulation-based medical education curriculum on advanced cardiac life support skills and its transformation to a mastery learning program. Curriculum development used the Kern 6-step model involving problem identification and general needs assessment, targeted needs assessment, goals and objectives, educational strategies, implementation, and evaluation and feedback. Curriculum maintenance and enhancement and dissemination are also addressed. Transformation of the simulation-based medical education curriculum to a mastery learning program was accomplished after a 2-year phase-in trial. A series of studies spanning 11 years was performed to adjust the curriculum, improve checklist outcome measures, and evaluate curriculum effects as learning outcomes among internal medicine residents and improved patient care practices. We anticipate wide adoption of the mastery learning model for skill and knowledge acquisition and maintenance in medical education settings.

Objective: This study evaluated the impact of a simulation-based mastery learning (SBML) curriculum on central line maintenance and care among a group of ICU nurses., Methods: The intervention included 5 tasks: (a) medication administration, (b) injection cap (needleless connector) changes, (c) tubing changes, (d) blood drawing, and (e) dressing changes. All participants underwent a pretest, engaged in deliberate practice with directed feedback, and completed a posttest. We compared pretest and posttest scores and assessed correlations between demographics, self-confidence, and pretest performance., Results: The number of nurses passing each task at pretest varied from 24 of 49 (49%) for dressing changes to 44 of 49 (90%) for tubing changes. At pretest, scores ranged from a median of 0.0% to 73.1%. At posttest, all scores rose to a median of 100.0%. Total years in nursing and ICU nursing had significant, negative correlations with medication administration pretest performance (r = -0.42, P = .003; r = -0.42, P = .003, respectively)., Conclusion: ICU nurses displayed large variability in their ability to perform central line maintenance tasks. After SBML, there was significant improvement, and all nurses reached a predetermined level of competency.

Introduction: Paracentesis procedures are increasingly performed in interventional radiology (IR) rather than at the bedside, and there are few comparative effectiveness data on safety or cost. There is also no consensus about the need for blood product transfusions before the procedure. In a previous study, we reported that the selection of procedure location was largely discretionary and that bedside procedures had equal or better outcomes than IR procedures. Therefore, the aim of this study was to evaluate direct hospital costs of IR paracentesis procedures compared with procedures performed at the bedside by simulation-trained clinicians., Methods: We performed an observational study of paracentesis procedures on a hepatology/liver transplant floor at a tertiary care hospital from July 2008 to December 2011. We modeled hospital costs for IR facility use and transfused blood products and calculated the cost of simulation training to compare costs between IR and bedside procedures., Results: Five hundred eighty-eight patients underwent 764 paracentesis procedures (331 in IR and 433 at bedside). Fifty-one patients (15.4%) with IR procedures received platelet transfusions versus 16 patients (3.7%) with bedside procedures (P < 0.001). Forty-nine patients (14.8%) with IR procedures received fresh frozen plasma transfusions versus 24 patients (5.5%) with bedside procedures (P < 0.001). There were no clinical differences in platelet counts or coagulopathy between groups. In random-effects logistic regression, IR procedures had significantly higher likelihood of platelet (odds ratio, 6.36; 95% confidence interval, 3.28-12.35) and fresh frozen plasma (odds ratio, 3.41; 95% confidence interval, 1.95-5.95) transfusions. Total costs were $663.42 per case for IR and $134.01 per case for bedside procedures., Conclusions: Training residents to perform bedside paracentesis procedures was highly cost-effective. This approach should be considered as part of national efforts to reduce hospital costs while providing quality care.

Introduction: Medical school graduates are expected to possess a broad array of clinical skills. However, concerns have been raised regarding the preparation of medical students to enter graduate medical education. We designed a simulation-based "boot camp" experience for students entering internal medicine residency and compared medical student performance with the performance of historical controls who did not complete boot camp., Methods: This was a cohort study of a simulation-based boot camp educational intervention. Twenty medical students completed 2 days (16 hours) of small group simulation-based education and individualized feedback and skills assessment. Skills included (a) physical examination techniques (cardiac auscultation); technical procedures including (b) paracentesis and (c) lumbar puncture; (d) recognition and management of patients with life-threatening conditions (intensive care unit clinical skills/mechanical ventilation); and (e) communication with patients and families (code status discussion). Student posttest scores were compared with baseline scores of postgraduate year 1 (PGY-1) historical controls to assess the effectiveness of the intervention., Results: Boot camp-trained medical students performed significantly better than PGY-1 historical controls on each simulated skill (P<0.01). Results remained significant after controlling for age, sex, and US Medical Licensing Examination step 1 and 2 scores (P<0.001)., Conclusions: A 2-day simulation-based boot camp for graduating medical students boosted a variety of clinical skills to levels significantly higher than PGY-1 historical controls. Simulation-based education shows promise to help ensure that medical school graduates are prepared to begin postgraduate training.

Introduction: Previous research shows that gaps exist in internal medicine residents' critical care knowledge and skills. The purpose of this study was to compare the bedside critical care competency of first-year residents who received a simulation-based educational intervention plus clinical training with third-year residents who received clinical training alone., Methods: During their first 3 months of residency, a group of first-year residents completed a simulation-based educational intervention. A group of traditionally trained third-year residents who did not receive simulation-based training served as a comparison group. Both groups were evaluated using a 20-item clinical skills assessment at the bedside of a patient receiving mechanical ventilation at the end of their medical intensive care unit rotation. Scores on the skills assessment were compared between groups., Results: Simulator-trained first-year residents (n = 40) scored significantly higher compared with traditionally trained third-year residents (n = 27) on the bedside assessment (91.3% [95% confidence interval, 88.2%-94.3%] vs. 80.9% [95% confidence interval, 76.8%-85.0%]; P < 0.001)., Conclusions: First-year residents who completed a simulation-based educational intervention demonstrated higher clinical competency compared with third-year residents who did not undergo simulation training. Critical care competency cannot be assumed after clinical intensive care unit rotations; simulation-based curricula can help ensure residents are proficient to care for critically ill patients.

Introduction: Interventions to reduce preventable complications such as catheter-related bloodstream infections (CRBSI) can also decrease hospital costs. However, little is known about the cost-effectiveness of simulation-based education. The aim of this study was to estimate hospital cost savings related to a reduction in CRBSI after simulation training for residents., Methods: This was an intervention evaluation study estimating cost savings related to a simulation-based intervention in central venous catheter (CVC) insertion in the Medical Intensive Care Unit (MICU) at an urban teaching hospital. After residents completed a simulation-based mastery learning program in CVC insertion, CRBSI rates declined sharply. Case-control and regression analysis methods were used to estimate savings by comparing CRBSI rates in the year before and after the intervention. Annual savings from reduced CRBSIs were compared with the annual cost of simulation training., Results: Approximately 9.95 CRBSIs were prevented among MICU patients with CVCs in the year after the intervention. Incremental costs attributed to each CRBSI were approximately $82,000 in 2008 dollars and 14 additional hospital days (including 12 MICU days). The annual cost of the simulation-based education was approximately $112,000. Net annual savings were thus greater than $700,000, a 7 to 1 rate of return on the simulation training intervention., Conclusions: A simulation-based educational intervention in CVC insertion was highly cost-effective. These results suggest that investment in simulation training can produce significant medical care cost savings.

Objective: To determine the effect of a simulation-based mastery learning model on central venous catheter insertion skill and the prevalence of procedure-related complications in a medical intensive care unit over a 1-yr period., Design: Observational cohort study of an educational intervention., Setting: Tertiary-care urban teaching hospital., Subjects: One hundred three internal medicine and emergency medicine residents., Interventions: Twenty-seven residents were traditionally trained and did not receive simulation-based education. These residents were surveyed regarding complications and procedural self-confidence on actual central venous catheters they inserted in the medical intensive care unit. Subsequently, 76 residents completed simulation-based training in internal jugular and subclavian central venous catheter insertions. Simulator-trained residents were expected to meet or exceed a minimum passing score set by an expert panel and measured by performance on a skills checklist (given both before and after the educational intervention), using a central venous catheter simulator. Simulator-trained residents also took a written pre and posttest. Simulator-trained residents were surveyed regarding complications and procedural self-confidence on actual central venous catheters they inserted in the medical intensive care unit., Measurements and Main Results: Simulator-trained residents reported fewer needle passes (p < .0005), arterial punctures (p < .0005), catheter adjustments (p = .002), and higher success rates (p = .005) for actual central venous catheters inserted in the medical intensive care unit than traditionally trained residents. At clinical skills examination pretest, 12 (16%) of 76 simulator-trained residents met the minimum passing score for internal jugular central venous catheter insertion and 11 (14%) of 76 residents met the minimum passing score for subclavian central venous catheter insertion: mean (internal jugular) = 50.6%, SD = 23.4%; mean (subclavian) = 48.4%, SD = 26.8%. After simulation training, all residents met or exceeded the minimum passing score at posttest: mean (internal jugular) = 93.9%, SD = 10.2; mean (subclavian) = 91.5%, SD = 17.1 (p < .0005). Written examination performance improved from mean = 70.3%, SD = 7.7%, to 84.8%, SD = 4.8% (p < .0005)., Conclusions: A simulation-based mastery learning program increased residents' skills in simulated central venous catheter insertion and decreased complications related to central venous catheter insertions in actual patient care.