Page 52 - JSOM Summer 2023

OA, RH), with a separate author (TD) resolving conflicts. The Four CPGs from the available 78 CPGs on the JTS database
group determined quantitative data needs using the delphi were identified as relevant. Two U.S. military surgical train-
consensus. After quantitative extraction, the “mini-delphi” ing programs, EWS and ASSET, as well as the curricula from
technique was utilized to extract qualitative data and themes. the Navy, Air Force, and Army Navy pre-deployment training
TD was the facilitator for all delphi rounds and consensus was were identified. Pertinent curricula information was extracted
reached by all authors. and summarized to isolate the high-yield data and themes re-
lating to pre-deployment vascular access proficiencies below
Inclusion criteria were English-language articles published (Table 2).
from 2001 to present, primarily discussing the following:
vascular access training with or without complication rates Discussion
(central and peripheral intravenous lines, arterial lines) in an
adult (defined as at least 18 years of age) in a military hospital, Scant literature was found to exist on ideal vascular access train-
deployed, or training setting. Exclusion criteria were pediatric ing for the non-surgical military provider. Three studies com-
populations, civilian-only institutions, and dates prior to 2000 mented on techniques and training modalities, demonstrating
since ultrasound (US) technology was not widely available that combination didactics and hands’ on skills sessions with or
prior to this date. Mixed population studies were evaluated without patient scenarios promoted greater skill retention. 14–16
for inclusion on a case-by-case basis (Figure 1). Additionally, in austere environments or situations in which US
was not available, supraclavicular access had the highest rate of
success. 15,17 Three studies commented on complications, includ-
FIGURE 1 PRISMA diagram demonstrating literature review strategy. ing infection, “backwalling,” and pneumothorax. 15–18 Notably,
an increased number of attempts was associated with reduced
19
successful cannulation rates. A single study compared differ-
ent catheter bores and tunneling, indicating that while ports are
the safest central line catheter for patients, they are expensive
20
and for chronic issues only. CPGs were reviewed and were
limited on guidance for vascular access because all CPGs as-
sume successful cannulation when providing further guidelines.
Training centers were contacted and ubiquitously noted that
while some opportunity exists for almost all relevant providers
to practice vascular access skills, there are no comprehensive
checklists, feedback mechanisms, or competency skills checks
associated with available training. Second, a lack of unified and
accessible training existed between centers, and the number of
high fidelity and training opportunities differed between sur-
geons and non-surgeons. There were no paradigms in place to
evaluate the provider to ensure competency, safety, or effective-
ness in troubleshooting unexpected outcomes.
Theoretical and functional knowledge about anatomy, ana-
Quantitative data from the literature search, such as compli- tomical variants, complications, and problem-solving are the
cation rates, individual skills confidence rates, and rates of cornerstones that must be built upon and revisited prior to
technical skills proficiency, were summarized in table format or during deployment, in which standard simulation (SIM) or
(Table 1). Pertinent qualitative data such as the components training opportunities do not currently exist. Potential com-
of various vascular access training programs in the literature plications, troubleshooting mistakes, and salvage techniques
were also identified and reviewed. are essential components of this foundational knowledge as
well. Combining the results of this review with existing civilian
Additionally, current Joint Trauma System (JTS) CPGs were vascular access training literature, three-tiered levels could be
reviewed, between January 2020 and July 2021 to assess the utilized for the most comprehensive and ideal vascular access
current state of practice within the military. The major Naval, training (Figure 2).
Air Force, and Army pre-deployment training centers or rep-
resentatives were contacted and asked to supply information The first tier, knowledge acquisition or a “see one” oppor-
relevant to current pre-deployment curricula for both surgical tunity, can occur in a virtual realm, making training both
and non-surgical providers. Searches and inquiries were per- cost-effective and readily accessible with a phone or tablet ap-
formed between July 2021 and December 2021. plication. Multiple procedural training opportunities with 3D
interactive models, active feedback, and “trouble shooting”
modes already exist within the MHS and are currently under-
Results
going stages of validation. This interactive, virtual training
21
The initial literature search identified 78 articles. Based on platform could be built into existing military platforms such as
screening and predetermined exclusion criteria, 71 articles Deployed Medicine for quick and easy access for any military
were excluded. The seven remaining included were then an- provider regardless of location.
alyzed for pertinent quantitative and qualitative/thematic
findings relevant to vascular access training opportunities as The second tier of an effective curriculum consists of apply-
well as complications and organized in the following chart ing virtual knowledge acquisition into hands-on procedural
(Table 1). opportunities, a “do one” first via simulation, which has

50 | JSOM Volume 23, Edition 2 / Summer 2023