Benchmarking procedural competence in paediatric intensive care using cumulative sum analysis: intravenous access, arterial lines and intubation

Objectives

There are no benchmarks for assessing competence for paediatric intensive care (PICU) procedures such as peripheral (PVL), central venous (CVL), and arterial cannulation (ART) and intubation. We evaluated PICU trainee competence using the cumulative sum analysis method (CUSUM) against data published for elective anaesthetic procedures in adults [1, 2]. Our objective was thus to document whether the suggested procedural failure rates for adults are applicable in PICU and the number of cases required to achieve procedural competence.

Method

We prospectively recorded outcome for procedures (PVL, CVL, ART, intubation) performed in a tertiary PICU by residents (n = 6) and fellows (n = 10) over a 4-month period. A successful procedure was defined as: PVL = cannulation with two or less punctures at a single site, CVL = cannulation with two or less punctures at a single site in 10 min, ART = cannulation with two or less punctures at one site within 10 min, and intubation = endotracheal tube entry into the trachea on the first attempt with two or less laryngoscopy attempts. Change in site or operator was recorded as failure. Ultrasound was used in 8% of CVL insertions. The CUSUM method calculates a weighted score for each procedure using predefined acceptable (p0) and unacceptable failure rates (p1). Success is weighted as s = [log(1 - p1) / (1 - p0)] / {[log(p1 / p0)] + [log(1 - p1) / (1 - p0)]} and failure as (1–s). The cumulative sums of these values are plotted on a time chart with an upward slope indicating failure (1–s) and downward slope success(es) for each group (residents and fellows). Competence is defined as the point where the downward slope crosses the lower control limit using an α and β error of 0.1.

Results

Eight hundred and seventy-six procedures were performed on 561 patients (mechanical ventilation 82%, inotropes 27%.) Median (IQR) age 6.3 months (1.1–34), weight 6.4 kg (3.3–13.6) and PIM2 score 2.9 (1.3–7.2). Thirty-four per cent of procedures were performed by residents and 66% by fellows. The number of procedures required to achieve competence for each group is shown in Table 1, with residents not achieving competence for any procedures except PVL insertion. Fellows failed as a group to gain competence for CVL insertion. Figure 1 contains the CUSUM plots for ART insertion by fellows and residents (group plot).

Table 1

Figure 1

Conclusion

The suggested procedural failure rates for adults (PVL 20%, CVL 5%, ART 20% and intubation 5%) are applicable in the PICU setting. Competence was achieved by PICU fellows within 27–36 procedures, except for central line insertion that may be improved by routine use of ultrasound guidance. A 4-month period does not provide PICU residents with sufficient exposure to gain competence for the central venous and arterial cannulation and intubations.