Clinical Performance and Skill Retention after Simulation‐based Education for Nephrology Fellows

Abstract

We previously demonstrated that simulation-based education (SBE) improved temporary hemodialysis catheter (THDC) insertion skills by nephrology fellows. SBE, featuring deliberate practice and rigorous achievement standards, was a powerful method to enhance THDC insertion skills in nephrology fellows. However, experts have called for further research to evaluate skill transfer from the simulated environment to actual clinical care and skill retention. This is a prospective observational cohort study of THDC insertion skills. Twelve nephrology fellows from three academic centers in Chicago were evaluated using a skills checklist from July 2008 to June 2009. Simulator-trained fellows were tested after the SBE intervention and expected to meet or exceed a minimum passing score (MPS) set by an expert panel. To assess transfer of skill to clinical care, three simulator-trained fellows were assessed at 6 months on actual patient THDC insertions using the checklist. To assess retention of skill, 11 of 12 simulator-trained fellows were reassessed at 1 year using the checklist and central venous catheter simulator. Outcomes were determined by THDC insertion skill performance. Simulator-trained fellows scored similarly during 6-month THDC insertions on actual patients and immediate posttest (M = 86.2%, SD = 22.3% vs. M = 93.5%, SD = 5.3%, p = 0.32). However, 1 year after SBE, simulated THDC insertion scores were significantly lower than at immediate posttest (M = 73.4%, SD = 22.2% vs. M = 93.5%, SD = 5.3%, p = 0.01). Our results show that nephrology fellows who completed SBE displayed high levels of performance during THDC insertions on actual patients 6 months later. At 1 year, there was statistically significant skills decay. We recommend booster training at 6 months.

Performance of Temporary Hemodialysis Catheter Insertion by Nephrology Fellows and Attending Nephrologists

“…Because of the results of this study and others, we recommend rigorous simulation-based training for clinicians who insert THDCs. SBML results in improved THDC insertion skills that are retained over time, translates into the clinical environment (14), and is cost effective (24,27). We previously showed that this training can be provided for a large number of clinicians as part of an annual nephrology meeting (7).…”

“…Younger attending nephrologists may be more familiar with ultrasound use during IJ THDC insertion than older attending nephrologists, which may have led to improved checklist performance. It is also possible that THDC skills deteriorate over time when physicians are mostly supervising and not personally performing the procedure (14). Additional study is needed to determine the best mechanism to prepare attending nephrologists to perform and supervise THDC insertions in clinical practice.…”

“…Prior research has analyzed the skills and confidence of nephrology fellows regarding THDC insertion and the benefit derived from SBML (6,7,14). However, little is known about the actual competence of supervising attending nephrologists to perform the procedure themselves.…”

Nephrologists as Educators

“…We were left with 30 (41%) articles after applying the exclusion and inclusion criteria. Six articles were related to student learning (3)(4)(5)(6)(7)(8), five were related to postgraduate trainees (9-13), and 19 were related to fellows or fellowship training (1,(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31). None of the articles had teachers or faculty members as subjects of the educational investigation.…”

Educational Tools

“…Additional research in specialties, including nephrology, shows that, although initial training on simulators may show improved skills or capability in the learning, over time, there is a fairly significant decline, indicating that perhaps the strength of simulation is in ongoing training and practice, where all levels of learners return periodically to test and improve themselves (35). Okuda et al (36) summed it up nicely by concluding that most medical students, residents, and fellows will now do a fairly significant amount of training on simulators but relatively little data exist on the ultimate outcome of this work on patient outcomes.…”