Central venous catheter (CVC) insertion is a common procedure that residents across various medical and surgical specialties are expected to perform early in their training. Despite being considered a “routine” procedure, CVC insertion can lead to complications, including bleeding, infection, pneumothorax, hemothorax, arrhythmia, air embolism, stroke, and even death [1]. Simulation-based training (SBT) has been shown to improve residents’ comfort in performing this procedure and reduce the likelihood of complications [2-4]. Therefore, we developed a case-based CVC simulation curriculum to improve resident comfort in obtaining informed consent, identifying relevant anatomy, maintaining sterile precautions, performing the procedure, and managing complications.

SBT for CVC insertion is gaining increasing interest among medical training institutions as an effective tool for improving procedural success rates and reducing complications [5,6]. Several institutions have implemented policies requiring the completion of a CVC training curriculum before residents are permitted to perform CVC insertions. Supporting this practice, a recent meta-analysis concluded that simulation-based CVC curricula were effective in improving learner performance outcomes on simulators, increasing knowledge and confidence, decreasing the number of needle passes required, and reducing the incidence of pneumothorax [7].

One major barrier to the widespread implementation of CVC curricula is the significant cost and resource requirement associated with SBT. Furthermore, there is considerable heterogeneity in the literature regarding the design and structure of CVC curricula, making it difficult to determine which design features and aspects are most effective [7,8]. To facilitate institutional adoption of CVC training programs, a variety of validated CVC curricula must be available to align with institution-specific requirements.

This study evaluated the effectiveness of our institution’s CVC simulation curriculum, contributing to the limited but growing body of CVC training programs. Specifically, this study aimed to determine whether our simulation-based CVC curriculum improved residents’ confidence and comfort with CVC insertion.

First-year resident physicians from various graduate medical education programs at a small medical center with approximately 50 patient beds voluntarily participated in the study between 2017 and 2023. All participants were first-year residents with no formal training in CVC insertion.

Participants were surveyed to assess their comfort with CVC insertion before and after completing a simulation-based curriculum focused solely on internal jugular vein (IJV) cannulation. Although our curriculum includes instructions for both IJV and subclavian vein cannulation, this study focused exclusively on IJV cannulation, given the constraints on time and resources. The IJV access was chosen over the subclavian vein access because it is the most commonly used central access site in clinical practice. The survey employed binary (yes/no) responses to assess comfort with the essential components of CVC placement, including indications, contraindications, informed consent, equipment, technique, and management. After completing the pre-survey, participants underwent a structured simulation curriculum.

The curriculum consisted of a brief didactic session, a critical action checklist, a case-based simulation, an evaluation, and a debriefing session (Supplementary Data), lasting approximately 2 hours. General surgery residents with at least two years of residency training performed the training. Participants received constructive feedback, and the simulation was repeated until they were able to correctly perform all critical actions independently.

Six months after the successful completion of the simulation curriculum, participants completed a post-survey identical to the pre-survey. This time interval was chosen to allow residents to gain experience inserting central lines in actual patients during their various clinical rotations.

Comfort scores were calculated for each participant as the percentage of “yes” responses in their survey. Changes in comfort were assessed by comparing the differences in comfort between the pre- and post-survey responses. Procedural variables included sterile procedures, patient positioning, and both supervised and unsupervised CVC placement, while all other variables were categorized as nonprocedural.

Survey data were aggregated and analyzed using Microsoft Excel. Mean comfort scores were calculated for the pre- and post-training surveys. A paired t-test was performed to evaluate the significance of differences between mean comfort scores before and after training. The McNemar test was used to assess the statistical significance of changes in individual questionnaire items.

This study was reviewed by our institutional review board, and approval was waived because it was classified as a quality improvement and/or program evaluation project.

Overall, 118 first-year residents participated in the study between 2017 and 2023. Among them, 57 (48%) completed both the pre- and post-surveys and were included in the analysis. These residents came from six different programs, including non-categorical interns and first-year residents from defined specialties, as follows: non-categorical interns (37%), general surgery (34%), internal medicine (11%), family medicine (9%), orthopedic surgery (7%), and oral and maxillofacial surgery (2%) (Fig. 1).

Figure 1. Breakdown of participants by various specialty.

Following completion of the SBT, the overall mean comfort level with CVC insertion increased from 42.1% to 81.3% (P<0.01) across the entire study participants.

Before the SBT, the highest comfort levels were reported for sterile procedures (86.0%) and supervised CVC insertion (82.5%). In contrast, the lowest comfort levels were observed for managing complications (9.3%) and performing unsupervised procedures (13.0%).

After the SBT, comfort level was highest for obtaining informed consent (98.2%) and lowest for performing unsupervised CVC insertions (29.6%).

Comfort levels significantly increased in all assessed categories, with the exception of supervised CVC insertion (Table 1). The largest improvement was observed in understanding the indications for CVC placement (62.5%, P<0.05) and interpreting results (59.6%, P<0.05). In contrast, the smallest changes were observed in sterile procedures (10.5%, P<0.05) and supervised CVC insertion (12.3%, P>0.05).

Table 1 . Mean change in comfort level by items for pre- and post-training.

Comfort (%)
Item	Pre	Post	Change	Significance
Indication	33.9	96.4	62.5	P<0.05
Consent	64.9	98.2	33.3	P<0.05
Anatomy	50.0	94.6	44.6	P<0.05
Equipment	36.8	87.7	50.9	P<0.05
Sterile procedurea	86.0	98.5	10.5	P<0.05
Positioninga	60.7	96.4	35.7	P<0.05
Interpretation	28.1	87.7	59.6	P<0.05
Superviseda	82.5	94.7	12.3	P=0.07
Unsuperviseda	13.0	29.6	16.7	P<0.05
Complications	9.3	46.3	37.0	P<0.05

^aIndicates procedural variables..

As pre-SBT comfort scores were already high for sterile procedures and supervised CVC insertion, post-SBT surveys showed limited room for improvement.

When analyzed by year, each cohort demonstrated an increase in overall comfort (range: 28%-45%) (Fig. 2). However, the response rates of the post-SBT surveys showed discrepancies between the year cohorts, which precluded further statistical analysis.

Figure 2. Comfort level increased post-training for each consecutive year group.

These results support the effectiveness of our SBT-based CVC curriculum in increasing resident comfort in most aspects of CVC insertion. Interestingly, comfort with nonprocedural aspects, such as obtaining informed consent, understanding indications, and interpreting results, showed notable improvement. In contrast, procedural skills, including adherence to sterile procedures and performing CVC insertions, showed relatively modest improvement.

Importantly, the ceiling effect was likely a contributing factor to the modest improvements in comfort with sterile procedures and supervised CVC insertions (10.5% and 12.3%, respectively). Both categories had high pre-training comfort levels (86.0% and 82.5%, respectively), limiting the potential for further improvement. Additionally, adherence to sterile procedures is not unique to CVC insertion, and participants may have previously developed competency in this area through other clinical experiences, such as surgical rotations.

Understanding why participants reported high comfort with supervised CVC insertion prior to training is more challenging. One possibility is that the participants had prior training or experience in CVC insertion. Alternatively, participants may have underestimated the complexity and technical skills required for the procedure. Assessing participants’ baseline knowledge and prior experience before undergoing this curriculum could help identify which aspects should be emphasized or streamlined for greater efficiency.

This study aligns with the growing body of literature supporting the use of SBT for CVC insertion [3,4,7,8]. The finding that participants were comfortable performing CVC insertions under supervision but remained less comfortable performing them independently after training suggests that while the simulation curriculum prepares residents for supervised procedures, it does not fully equip them for independent CVC insertion.

CVC insertion requires multiple technical skills that take time and repeated practice to master [5,7]. While a simulation-based CVC curriculum cannot fully replace hands-on clinical practice, our findings demonstrate that it is both feasible and effective in providing residents with the prerequisite knowledge and skills needed to begin supervised CVC insertions with confidence and comfort.

This study has several limitations. First, we did not collect data on external factors that may have influenced residents’ comfort with CVC insertion, such as prior clinical experience or additional training received within 6 months of completing our curriculum. Second, although procedural competency was evaluated during the initial training, it was not reassessed at the time of the post-survey. As a result, we could not determine whether increased comfort corresponded to actual improvements in procedural competency. Third, the study had a low post-survey response rate (48%), as residents were drawn from multiple residency programs, making individual follow-up challenging. Additionally, the absence of incentives for completing the post-survey may have contributed to the low response rates.

To address these limitations, we plan to include additional post-survey questions to capture other facts that may influence comfort with CVC insertion, such as the number of central lines placed and any additional training received. Furthermore, we will implement a follow-up SBT session six months after the initial training to reassess participants’ competency in CVC insertion.

Overall, this study supports the effectiveness of a simulation-based curriculum in enhancing residents’ comfort with CVC insertion. Our training improved not only procedural comfort but also understanding of indications and management of complications.

Implementing a similar SBT-based CVC curriculum at additional institutions may help reduce complications associated with CVC insertion by better preparing residents.

None.

Supplementary data can be found via https://doi.org/10.5758/vsi.240079

The authors have nothing to disclose.

Concept and design: JB. Analysis and interpretation: all authors. Data collection: MA, JB, MC, JS, EC, AA, JL, FK, DC. Writing the article: DC, FK, MC, TK. Critical revision of the article: MA, JB. Final approval of the article: JB. Statistical analysis: DC, MC, FK. Obtained funding: none. Overall responsibility: MA.