Plan-do-check-act was applied to improve the first success rate of radial artery catheterization in anesthesiology residents

doi:10.21203/rs.3.rs-3204480/v1

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Plan-do-check-act was applied to improve the first success rate of radial artery catheterization in anesthesiology residents

https://doi.org/10.21203/rs.3.rs-3204480/v1

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Background:In the Department of Anesthesiology, radial artery puncture and catheterization is a basic skill for every doctor. Invasive arterial puncture directly measures the blood pressure value through the catheter, realizing real-time accurate monitoring of blood pressure fluctuation in critically ill patients, which provides the basis for clinical diagnosis and treatment; at the same time, part of the test specimen can be retained through the end of the invasive arterial catheter, which reduces the complications brought about by frequent blood collection and puncture. Therefore, we need to improve the success rate of the first attempt of radial artery catheterization in anesthesiology standardized training residents.

Objective:Improving the success rate of first attempt radial artery cannulation in anesthesiology standardized training residents.

Methods:Forty anesthesia residents undergoing standardized residency training at Sichuan Provincial People's Hospital from January to May 2023 were randomly divided into a control group and a PDCA group, with 20 residents in each group. The control group received standardized training with routine management and radial artery puncture and catheterization teaching; the PDCA group received training with PDCA cycle management and radial artery puncture and catheterization teaching. The success rate of the first attempt of radial artery cannulation, duration of radial artery cannulation, ultrasound use rate, whether the items were prepared with missing items and complication rate of the standardized training residents in the two groups were recorded and analyzed.

Results:One resident physician in the PDCA group did not participate in the assessment due to illness, so a total of 19 physicians in the PDCA group participated in the assessment, and all 20 physicians from the control group participated in the assessment.The first success rate of puncture in the PDCA group was 85% (17/20), which was significantly higher than that of 45% (9/20) in the control group (P=0.003).The time of radial artery cannulation after PDCA was 0.92(0.63,2.73) min, which was significantly shorter than that of 3.84(2.87,5.65) min in the control group (Z=4.68, P<0.05).The ultrasound utilization rate in the PDCA group was 45% (9/20), which was significantly higher than the 15% (3/20) in the control group (P<0.05). There was no statistically significant difference in item preparation omissions, assessment scores, and complication rates in the PDCA group of residents in the operational assessment compared to the control group.

Conclusion:PDCA management helps to increase the success rate of radial artery cannulation on the first attempt, shorten the time to puncture and place the cannula, increase the rate of complete preparation of items, as well as reduce the rate of complications.

Plan-do-check-act

Teaching method

Standardized training residents

radial artery

anesthesiology

In anesthesiology,the radial artery is the most commonly used site for arterial puncture placement because it is superficially located and the radial artery has collateral circulation and a low incidence of ischemic complications, radial artery cannulation may be the first choice for arterial cannulation.Before radial artery cannulation,the ulnar artery collateral circulation should first be assessed by Allen's test or modified Allen's test as a rule[1]. Second, invasive arterial waveforms are used to calculate Stroke volume variation(SVV) and pulse pressure variation (PPV) are the main targets for fluid volume measurement.The SVV and PPV help to evaluate the fluid volume status of the patient and also help to reflect the rationality of fluid management,and often become the main reference target of Goal directed fluid therapy(GDFT)[2].However,there are still some risks associated with radial artery puncture,such as local hematoma,pseudoaneurysm,thrombus or embolism,and infection.Therefore,there is a need to improve the technique of radial artery cannulation[3, 4].

With the advancement of standardized residency training, standardized training residents have become an important part of the front-line clinical staff in the Department of Anesthesiology[5]. Improving the quality of standardized residency training not only promotes the growth of residents, but also ensures the medical safety of patients, which is likewise the focus and difficulty of clinical teaching in the Department of Anesthesiology[6].

The PDCA cycle is a continuous improvement model that consists of four phases: plan, do, check and action, which is a snowballing cycle of constant intervention on the management objectives to achieve the goal of solving problems. Through the continuous PDCA cycle, we can gradually solve the problems in quality management and achieve standardized management[7, 8].

The study was to apply the PDCA cycle management method to the teaching of radial artery puncture and cannulation to anesthesiology residents in a teaching tertiary care hospital, and then to assess whether the PDCA cycle management method has superiority and generalizability compared with the traditional teaching methods in anesthesia clinical teaching. By applying the PDCA cycle to the training and quality management of radial artery cannulation for anesthesiology residents in standardized training, we summarized the main reasons for the multiple failures of radial artery cannulation in the Department of Anesthesiology, and put forward corresponding corrective measures for each of the reasons, which ultimately improved the success rate of radial artery cannulation on the first attempt for residents in standardized training, shortened the time of cannulation, improved the rate of complete preparation of items, and reduced the complication rate. The study is summarized as follows. The study is summarized as follows.

Teaching methods

Control group:adopting traditional teaching methods,before teaching,the residents will study the national standardized training materials for residents and review the theoretical basics related to radial artery puncture and catheterization (including radial artery anatomy, the significance of Allen's test and measurement value, puncture and catheterization steps, as well as the prevention and treatment of complications)[9]. On the day of teaching, the instructor will demonstrate one-on-one standardized operation and teach the operation steps and key points, and answer and solve the questions raised by the residents in the process of apprenticeship[6].

PDCA Group:Plan,We reviewed the relevant literature to optimize the training program and clarify the training objectives[10, 11]. We used a fishbone diagram to summarize the possible factors affecting the success rate of radial artery cannulation. In response to the main reasons analyzed above,the PDCA project team developed PDCA management goals.Do,We developed standardized operating procedures with reference to the radial artery puncture and cannulation section of the national standardized residency training materials and distributed learning materials to residents for training. We conducted training once a month through slide presentations, videos, and bedside teaching. According to the hospital's invasive access system, after training and assessment, residents can participate in radial artery cannulation as first assistants. After serving as a first assistant for greater than or equal to five times, the resident may qualify as a primary operator.Residents are required to use ultrasound for vascular assessment and puncture site localization prior to the procedure. Check,Supervise the implementation of standardized procedures, which are then accurately documented by the supervising physician during the procedure. Require accurate documentation of the operator's name and situations encountered during the procedure.Act,analyze the reasons affecting the success rate of radial artery cannulation in order to define the goals for the next phase of management. Summarize the residents' knowledge blind spots and operational errors in practice, which will be the focus of the next phase of training.

Assessment method

Forty standardized training residents in anesthesia who underwent standardized residency training at Sichuan Provincial People's Hospital from January to May 2023 were assessed for radial artery puncture and tube placement. The assessment included: (1) the number of items missed in the preparation of preoperative items; (2) the score of standardization of operation steps (the assessment items included pressure kit preparation and arterial pressure zeroing, disinfection of toweling and local disinfection/local anesthesia, puncture angle and position, placement and fixation of tubes, and asepsis, with 20 points for each of the 5 items); (3) the success rate of the first operation (if the third puncture is still unsuccessful, then it will be performed by the supervising physician) ; (4) duration of radial artery puncture and tube placement; (5) ultrasound utilization rate; and (6) occurrence of complications.

Observation indicators

The operational assessment of the control and PDCA groups was compared between the groups, including (1) Success rate of the first attempt: successful placement of the catheter with only one insertion in the radial artery puncture; (2) Duration of radial artery puncture and placement: the duration from the radial artery puncture to the fixation of the catheter; (3) Ultrasound utilization; (4) Incidence rates of complications (Incidence of complications): including local hematoma, ecchymosis, infection, pseudoaneurysm, thrombus, embolism, and infection. (5) Number of missed items in preparation; (6) Operation standardization score.

Statistical analysis

SPSS 22.0 software was used for statistical analysis. Measurements conforming to normal distribution were expressed as mean ± standard deviation, non-normally distributed measurements were expressed as median and interquartile spacing, and count data were expressed as frequency and percentage.Shapiro-Wilk test was used for normality test. Levene's test was used for homogeneity of variance. When the measured data conformed to normal distribution and homogeneity of variance, t-test was used for comparison between groups. Nonparametric tests were used for data that were not normally distributed and homogeneity of variance, and Mann-Whitney U rank sum test was used for comparison between groups. Count data were compared by taking X² test and Fisher's exact probability method was used when the actual frequencies were small. The test level was α = 0.05.

PDCA cycle

We used the PDCA cycle to develop a training plan and optimize quality control (Fig. 1). By reviewing the literature we used a fishbone diagram to summarize the factors that may influence the success rate of radial artery cannulation (Fig. 2).

Baseline of operators

40 anesthesiologists who underwent standardized residency training in Sichuan Provincial People's Hospital were randomly divided into a control group and a PDCA group, with 20 in each group. Compared with the control group, there were no significant differences in age, gender and education in the PDCA group (Table 1).

Operational assessment results

Compared with the control group, the success rate of the first attempt in the PDCA group was 85%, which was significantly higher than the success rate of the first attempt in the control group, which was 45% (p < 0.05).The duration of radial artery puncture catheterization and placement in the PDCA group was 0.92 (0.63,2.73), which was significantly lower than the radial artery puncture catheterization and placement in the control group, which lasted for 3.84(2.87,5.65) (p < 0.05).In the PDCA group The ultrasound utilization rate was 45%, which was significantly higher than the control group ultrasound utilization rate of 15% (p < 0.05). The difference in item preparation omissions and assessment scores during the operative assessment was not statistically significant in the PDCA group of residents compared to the control group. Only one resident in the control group had a hematoma at the puncture site due to improperly disposed compression hemostasis for failed puncture during all assessments(Table 2).

Radial artery puncture and cannulation, as a commonly used monitoring tool in anesthesiology today,is a basic skill that every anesthesiology resident should standardize and master[12].Errors and irregularities in radial artery puncture and cannulation often lead to errors and irregularities in radial artery puncture and cannulation often lead to hematoma and infection at the puncture site, radial artery injury (spasm or entrapment), thrombosis, and even hand blood supply disorders, which seriously affect the safety and efficiency of clinical anesthesia, and therefore, efficient and comprehensive teaching of the operation is of great significance[13]. When residents train in anesthesiology departments, they often have insufficient relevant knowledge and practical experience. However, patients in anesthesiology departments often have complex comprehensive states and critical situations, which puts high demands on operators[14].

The traditional teaching method is based on the resident's clinical internship process, and subject to the actual clinical work of fast turnover, large changes in staffing arrangements, the patient's psychological tension and other factors, it is often not possible for one instructor to complete a comprehensive standardized teaching and related knowledge; and due to the first contact with the clinical work of the resident in the new environment of the adaptation period and the existence of nervousness, for the different instructors of different techniques, there is no uniform standard demonstration process is prone to memory confusion[15]. Moreover, because residents are nervous about the different teaching methods of different instructors and the lack of standardized teaching process, they are prone to memory confusion. All of this leads to the need for more internships and a longer period of time for residents to comprehend,memorize,integrate, and practice under traditional teaching methods[16].

To address the shortcomings of traditional teaching methods in the application of basic anesthesia operations, this study adopts the PDCA cycle management method to teach radial artery puncture catheterization to anesthesiology residents in teaching tertiary hospitals, and the advantages of this method are: (1) It can comprehensively transmit the complete standard operation process and the knowledge framework to the residents in a relatively short period of time to enable them to form the most initial coherent and correct memory. (2) Monthly slide presentations, videos, and bedside lectures eliminate the residents' nervousness about the actual work and allow them to focus more on learning and memorizing the knowledge. (3) With the help of slide show, video and bedside teaching to present the clinical operation process of undergraduates, the dosage forms of heparin and local anesthesia drugs, sterile packs and sheets, pressure kits and arterial puncture needles, and the types of monitors are consistent with those used by residents at work, which is of more practical teaching and guidance significance, and this is also the reason why the omission of items in the preparation of items in the operation examination of the residents in the PDCA group is significantly lower than that in the control group. This is also the reason why the residents in the PDCA group had significantly lower item preparation omissions in the operation examination than those in the control group. (4) The slides and videos can be saved and watched repeatedly by the residents themselves, and the PDCA cycle management improved the proficiency of the operating physicians, so the first-attempt puncture success rates in the PDCA group were significantly higher than those in the control group, and the duration of catheterization in the PDCA group was significantly lower than that in the control group. was significantly lower in the PDCA group than in the control group.

In the PDCA cycle management, we implemented bedside teaching with the help of ultrasound technology[17–19], which may be the reason why the rate of ultrasound utilization in the PDCA group was significantly higher than that in the control group. Ultrasound, as a means of visual teaching, can assist in theoretical and operative demonstration to bring out the key aspects of clinical practice in a clear and visible manner. By selecting student volunteers and conducting rotating ultrasound exercises on the radial artery, residents can gain an in-depth visual understanding of the anatomical positioning of the radial artery in the human body with its depth, diameter, proximity, and course; and by combining it with mold puncture and tube placement exercises and instructions, learners can further practice aseptic operation and experience the angle of needle insertion and puncture, as well as the operation techniques. The visualization teaching method greatly stimulates the residents' interest and initiative in learning due to its fun and hands-on nature, and deepens their memory on the basis of in-depth reinforcement of theoretical and operational knowledge; at the same time, it effectively avoids the residents' nervousness due to the first-time operation on patients and potential medical disputes. After the PDCA cycle management, the skill level of standardized training residents in operating radial artery cannulation has improved, which is also the reason for the higher ultrasound utilization rate in the PDCA group. In addition, detailed training and quality control requirements helped to develop a rigorous work style among the residents.

Goal orientation is important not only in PDCA management but also in clinical teaching. Scientific and correct goal setting is an important factor in achieving good results in PDCA management. In this study, we asked the standardized-trained residents to achieve the operational principles of "accuracy, stability, and speed". First, we should avoid repeated puncture whenever possible. When time permits, it is best to spend enough time to understand the vascular anatomy and to prepare adequately. Secondly, the operation needs to comply with the standard and must pay attention to various details. Trying to be as fast as possible is the last requirement.

PDCA cycle management can help to improve the success rate and shorten the time of radial artery puncture and catheterization in patients of quasi-trained residents.The PDCA cycle management method is more superior than the traditional teaching method for teaching radial artery puncture and catheterization in anesthesia residents, and it can be promoted and applied to the training and management of various skills in residents.

Limitations

The main limitation of this study is that the conclusions of this study are based on a single center only with a relatively small sample size. We should therefore be mindful of these limitations when reviewing this study.

Ethics approval and consent to participate

All methods in this study were performed in accordance with relevant guidelines and regulations. The Ethics Committee of Sichuan Provincial People's Hospital waived the need for ethical approval of the teaching study. No human specimens were collected for this study. This study does not fall within the scope of ethical review of biomedical research involving humans.Informed consent was obtained from all subjects and/or their legal guardians.

Consent for publication

Not applicable.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

All authors declare that they have no conflicts of interest.

Funding

We received research support from Sichuan Science and Tech[1]nology Program (Grant No: 2023YFS0193), MedicoEngineering Cooperation Funds from University of Electronic Science and Tech[1]nology of China (ZYGX2021YGLH221) and Sichuan Provincial Peo[1]ple’s Hospital Young Talent Fund (Grant No: 2022QN07).

Authors’ contributions

Meng Zhang:Dissertation Writing, Literature Review and Graphing;Shuchuan Zhao：Data analysis and processing；Fangjing Bai,Shanshan Yu：Data collection；Guangmin Xu：Instructional Management Planning and Instructional Delivery.All authors read and approved the final manuscript.

Acknowledgements

We thank the anesthesia preparation department of Sichuan Provincial People's Hospital for their support and guidance.

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No competing interests reported.

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Version 1

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You are reading this latest preprint version

Plan-do-check-act was applied to improve the first success rate of radial artery catheterization in anesthesiology residents

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Version 1

Abstract

Figures

Introduction

Methods

Teaching methods

Assessment method

Observation indicators

Statistical analysis

Results

PDCA cycle

Baseline of operators

Operational assessment results

Discussion

Conclusion

Limitations

Declarations

References

Additional Declarations

Status:

Version 1