How to structure a training course PICC: the recommendations of the consensus WoCoVA and GIPE Massimo Lamperti MD Consultant in Neuroanesthesia and Pediatric Anaesthesia, Cleveland Clinic Abu Dhabi, UAE  Where are we now?  Where are we going to?  Do we perform well? What was known (before) about training? •  Lack of evidence-based medicine •  Some position statements of Scientific Societies (RCR, ACEP, AMS) •  More based on a consolidated habits that on standards of education •  Total lack of objective criteria What about clinical training? •  Greater standardization in nurses training •  More attention in pediatrics and neonates (where the process is properly standardized and a final audit is considered mandatory) Consensus and guidelines •  WOCOVA: objective: to achieve a minimum proficiency level on central venous access placement and care •  GIPE: objective: specific requirements a PICC course must have to teach insertion / management of PICCs Differences WOCOVA/GIPE •  WOCOVA: EBM consensus with specific recommendations on minimal skills not only on trainees but also on trainers/supervisors •  GIPE: experts’ opinion, no-EBM based with the specific objective to create a network of centers with qualified experts in teaching PICC line insertion and management Why an EBM method? •  JCAHO and ISO certifications accept only EBM-based guidelines •  WOCOVA used the GRADE-RAND method which is considered by the Cochrane review as the gold standard method for writing statements after a consensus conference New EBM •  From level of evidence (I,Ia, IIa, IIb...) to new different levels of evidence (A=high,B=moderate,C=poor), levels of recommendation (strong/weak) and degrees of Consensus (very good/good/poor) between experts Wording based on Degree of Consensus & Grade of recommendations Degree of consensus GRADE of recommendation Wording Perfect consensus Strong recommend – must/to be/ will Very good consensus Strong recommend – should be/can Good consensus Strong recommend – may be/may Some consensus Weak Suggest- may be No consensus NO No recommendation was made regarding Main topics to be covered in a PICC course •  Theoretical teaching •  Ultrasound anatomy (knobology) •  Simulators •  Supervised training on patients •  Final audit Theoretical teaching •  Basic Ultrasound anatomy •  Physics of ultrasounds and ultrasound imaging (gain, depth, focus, freeze, NO Doppler in the basic ultrasound knowledge) •  Recognition of abnormalities/complications (major and minor) •  Maintenance / care of CIC Theoretical teaching •  Indications to the positioning of CICs and types of CICs •  Knobology (vascular, nervous, soft tissues) •  Ultrasound for venipuncture and control of complications •  Control of the tip of CIC •  Infection control and sterility Theoretical teaching •  Insertion procedure (maintaining sterility, kit preparation, ultrasound evaluation of pre-, intra-post control, fixation, dressing) •  Prevention, assessment and treatment of complications •  Proficiency rating with the GRS •  Specific aspects in the infant / child Anatomy •  Vascular anatomy, size, location, course •  Differentiation A / V with ultrasound •  Identification of skin changes •  Distribution and identification of peripheral nerve structures •  Respiratory Anatomy (not MANDATORY for the basic PICC course) Ultrasound lab •  How an US machines works •  RACEVA protocol •  CVR (catheter / vein) ratio •  CUS (compressive ultrasound) •  Choice of CICs (patient, treatment, length) Lab • Use of a checklist for choosing CICs • Use of checklist for PICC insertion • Recognition of the tip of the PICC -Intracavitary ECG (recommended) -chest x-ray (tip recognition/misplacements) -CEUS (contrast enhanced ultrasound) Lab Checklist for the maintenance and care of PICC: •  medication •  dressing •  washing techniques •  techniques for removing catheter’s clots or obstructions Lab How to replace a PICC in case of: •  rupture of the catheter •  thrombosis •  infection Teaching techniques •  Experiential learning: a model of learning, in which learning/meaning is derived from direct experience. Experiential learning can be attained in a reflective cycle such as Kolbs’ learning cycle. •  Experiential education: is a methodology where educators/mentors purposefully engage with learners in direct experience and reflection in order to increase knowledge, develop skills and clarify values Simulation training What you should teach? Each trainee should perform a PICC insertion starting from: •  Discussion on the clinical scenario •  Preparation of patient and materials •  Completion of the procedure with the greatest adherence to reality and within the bundles for infection prevention Simulation Training •  Communication with team members to assist the operator performing PICCs insertions •  Communication must be clear, effective and shared decision-making Anatomical models •  Must be able to reproduce the vascular component, soft tissues, muscles, bones •  There are already 3D models available that simulate the reality of human anatomy •  It is necessary to establish anatomic models with different characteristics Proficiency • Safety learning curve: with a 50% reduction of major complications • GIPE: proficiency based on a predetermined number of procedures (4) to increase in case of failure (up to 10) Example of a PICC course •  6-8 hours of theoretical education •  4 hours of practice on animal model •  Ultrasound lab: 4 hours in healthy volunteers •  Supervised practice until proficiency is achieved (from 4 to 10 according GIPE- GRS3 according WOCOVA) Audit and assessment of competence •  Use a logbook •  If trainees fail in a step, they have to go back to the previous step in order to be trained again (retraining back) •  For the theoretical part: passing score 70% of MCQs (at least 100) Final exam and evaluation of competence •  Final audit with the Global Rating Score that involves passing all the steps •  If the steps are not fully passed, the trainee must continue in practice until it gets full power and he/she is not recognized to perform the operation in an autonomous way •  Core privileges definition of PICC inserters Proctored supervision •  Mandatory during certified training •  Failure of the method "see one, do one, teach one" •  Experienced operators defined according to their proficency (not according to the number of installations itself) •  Core privileges definition of PICC trainers Trainer/supervisor core privileges •  Certified trainer •  Trainer have to maintain a clinical proficiency continuously in order to have a personal logbook and morbidity lower than other operators •  Have to be members of a IV team •  Must support and promote the culture of the IV team and IP team with regard to the prevention of CLABSI Training in neonates/paediatrics •  Dedicated to those who usually works in the field of neonates / paediatrics •  Staff already trained in the care of these patients •  Specialist training by the trainer •  Supervised training increased up to final GRS full autonomy Take home points •  Standardization of the educational programmes •  Minimal theoretical teaching defined •  Anatomical laboratory •  Laboratory on inanimate model •  Supervised practice on patients •  Final audit and objective evaluation method (GRS) Questions at: [email protected]