Virtual Reality: Emerging Technology in Vascular Access Education and Training
Author
Dagoberto Salinas, MSN, ACCNS-AG, CNOR, VA-BC 1
1 MGH Institute of the Health Professions, Boston, Massachusetts
Conflict of Interest Statement
I have a financial interest in SimX, a company that provides virtual reality medical simulation solutions. I will receive royalties from SimX Medical for my contributions to their virtual reality simulation platform.
Corresponding Author
Dagoberto Salinas, MSN, ACCNS-AG, CNOR, VA-BC, MGH Institute of the Health Professions, Boston, MA
(Email: dagobertosalinasjr@gmail.com)
Brief Description
The dire need to educate and train more vascular access specialists in response to nursing shortages in the U.S. calls for innovative solutions that promote cost-effective, safe, and reliable educational practices. Although traditional training modalities are more prevalent in qualifying new vascular access specialists, they are expensive and have limited realism. Virtual reality (VR) has shown promising results in enhancing critical thinking and technical abilities in the health professions and can outperform traditional methodologies when strategically implemented. Augmenting traditional vascular access training with VR modalities, specifically in PICC and midline insertions, should be strongly advocated.
Introduction
Vascular access specialists are critical in supporting patient care in inpatient and outpatient healthcare settings. When properly trained, vascular access specialists can perform a variety of highly skilled procedures, including but not limited to peripherally inserted central catheter (PICC), midline, and ultrasound-guided intravenous insertions (Dabadie et al., 2016; Ostrowski et al., 2019). In the U.S., vascular access specialists insert approximately 2.7 million PICCs annually (iData Research, 2020). Ubiquitous healthcare staffing shortages, however, present a threat to maintaining pace with this effort. Estimates show that the nursing workforce will need to increase by 6% (203,000 positions per year) between 2022 and 2032 to adequately support the complex healthcare system in the U.S. (McKinsey & Company, 2023; Nicolaus et al., 2022; U.S. Bureau of Labor Statistics, 2023). These foreseen challenges will also impact the demand for qualifying more vascular access specialists.
PICC and midline insertions have become more prevalent in the U.S. because of the ease at which they are placed at the patient's bedside; however, there are inherent risks associated with these venous catheters, including venous thromboembolisms (VTEs) and central line-associated bloodstream infections (CLABSIs). To mitigate the risk of VTE and CLABSI, evidence-based practice (EBP) strategies must be adopted that not only help clinicians master the technical process but also assist in determining when it is clinically appropriate to perform these procedures (Chopra et al., 2022). Ideally, vascular access curriculums focusing on PICC and midline catheter education should integrate all elements of clinical competency to promote competency: knowledge, skills, and attitudes (Abich et al., 2021).
PICC Lines
PICC lines are long, soft, flexible vascular access devices (VADs) that are inserted in the antecubital fossa or upper arm (basilic, brachial, or cephalic veins) and terminate in the superior vena cava (above the heart). Two common indications for inserting a PICC include 1) prolonged infusion therapy (longer than two weeks) and 2) administration of irritating medications or solutions. PICC sizes range between 1.2 - 6 French in diameter and 8 - 65 cm in length (Coulter, 2022). PICCs are usually introduced via the modified Seldinger technique (MST), which entails advancing a catheter over an access needle and withdrawing the needle (Song et al., 2018). The Infusion Nurses Society (INS) recommends using "maximal sterile barrier precautions" for all PICC insertions (Coulter, 2022).
Midlines
Midlines are soft, flexible VADs inserted in the antecubital fossa or upper arm (basilic, brachial, or cephalic veins) and terminate below the axillary region. Midlines are considered peripheral access devices recommended for non-vesicant solutions smaller than 900 mOsm with infusion duration shorter than four weeks. Midline sizes range between 1.2 - 5 French in diameter and 8 - 20 cm in length. Like PICC placements, midlines are commonly inserted via an MST approach and require maximal sterile barrier precautions to prevent contamination (Coulter, 2022).
PICC and midline insertions require specialized education and training that imparts knowledge of anatomy, physiology, infusions, policies/protocols, and indications for VAD selection (CVC Healthcare, 2022). Traditional course curriculums for conducting PICC and midline insertion training consist of two segments: 1) didactic session and 2) hands-on practicum. Of these two segments, the hands-on practicum presents the most variation. It is known to be disorganized and unstructured (Kondrashova et al., 2020). Phantoms, animal and synthetic models, computer-based training, and cadavers are examples of modalities used in traditional PICC and midline training courses. Table 1 outlines the pros and cons of each training modality. Although each training modality offers a unique experience, they are limited in their ability to simulate a holistic clinical experience that covers pre-procedural, procedural, and post-procedural tasks.
Virtual Reality
VR technology emerged in the 21st century as an influential tool in the education of healthcare professionals. VR uses computer technology to immerse learners into simulated environments that are three-dimensional and interactive. Because of its ability to alter perception within the confines of a classroom, VR has gained popularity over traditional training methods in the health professions (Johnson, 2023). Studies have demonstrated VR's superiority in improving healthcare professionals' knowledge and skills compared to traditional methods (Kyaw et al., 2019).
Adverse events associated with invasive procedures, such as central venous catheter insertions, are influenced by different patient conditions, anatomic variations, and unpredictable environmental stressors. Traditionally, the automatism of complex procedures is achieved through repetition using standard mannequins. However, this practice is not always practical. VR has shown strong practicality in enhancing clinical proficiency and patient safety by creating a more realistic and dynamic environment. Additionally, VR offers an advantage over traditional training with regard to cost, repeatability, and standardization capabilities (Savir et al., 2023). Through a mastery learning theory approach, VR can be leveraged to deliberately practice the essential skills needed in vascular access while maintaining cost-effectiveness (Pottle, 2019; Siddaiah-Subramanya et al., 2019).
Currently, VR simulation scenarios for PICC and midline insertions are unavailable in the marketplace. The unavailability of VR scenarios for vascular access training calls for developing an EBP-based VR vascular access curriculum with a robust simulation operations infrastructure. New VR technology can be successfully implemented by practicing interprofessional collaboration, carefully managing resources, referencing best practices for design, promoting the training of faculty and students, and sustaining a robust program evaluation process (Lie et al., 2023).
VR Clinical Scenario
VR PICC/Midline Simulation Template
To address the current competency gap that exists between the classroom setting and clinical practice, CLINSPEC Solutions, LLC invested in the development of a SimX VR vascular access curriculum that consists of two different simulation scenarios: 1) Establishing vascular access for long-term antibiotic therapy (PICC scenario) and 2) Establishing vascular access in a difficult intravenous access patient (midline scenario). The proposed VR simulation template design aligns well with INACSL best practices and intends to provide a roadmap for educators and operations specialists involved in training vascular access specialists. Figure 1 includes an example of a proposed template for a midline insertion.
The vascular access curriculum will also include key components that address assessment, debriefing, and program evaluation. The assessment plan will incorporate formative and summative elements to enhance knowledge, procedural skills, interpersonal communication, and professionalism (Kayingo & Hass, 2017). The debriefing tool is based on PEARLS principles, focusing on five basic steps: 1) setting the scene, 2) reactions, 3) description, 4) analysis, and 5) application/summary (Figure 2) (Bajaj et al., 2018). Lastly, program evaluation will be structured using two mixed methodologies: 1) Kirkpatrick's four-level evaluation model and 2) the CIPP (context/input/process/product) evaluation model (Frye & Hemmer, 2012). Assessment, debriefing, and program evaluation are critical components designed to complement the technical aspects of the VR simulation scenarios.
Results
The proposed vascular access curriculum, which includes both PICC and midline scenarios, is expected to be released in Spring 2024 (Figure 2).
Discussion
VR simulation has gained significant popularity in the health professions due to its practicality – can virtually be used anywhere and at any time. Nevertheless, VR specifications must be defined clearly during its development to set realistic expectations (Kardong-Edgren et al., 2019). The upcoming release of the first-ever VR vascular access curriculum for PICC and midline insertions does not intend to replace traditional methods, but to augment them. Once released, the curriculum can be adopted by a variety of entities, including but not limited to vascular access education companies, healthcare facilities, and academic institutions. Its ground up software development will allow for compatibility with any major VR headset brand, such as Oculus and Apple products (SimX VR, 2021).
The integration of evidence-based decision-making tools like the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) within the proposed VR vascular access curriculum represents a significant advantage. This special feature addresses the crucial imperative to minimize risks associated with venous catheterization in clinical settings, specifically with PICC and midline insertions. While the primary aim of the curriculum is to enhance the qualification of vascular access specialists, its versatility also makes it a valuable resource for maintaining and advancing the clinical competencies of seasoned healthcare professionals. This innovative approach not only contributes to the growth of skilled practitioners but also ensures a sustained commitment to patient safety and quality care in the realm of vascular access.
Limitations
The use of VR simulation can be associated with cybersickness, dizziness, and nausea, which are common challenges that need to be addressed for a more seamless user experience (Park & Lee, 2020). Also, it is essential to note that the absence of haptic feedback in this product underscores the importance of considering traditional modalities as alternative methods for psychomotor skills training. Despite the lack of haptic feedback, the benefits of VR in facilitating comprehensive assessments cannot be overlooked. VR proves to be a valuable tool for integrating various aspects of learning and skill development, and its learning outcomes are comparable to those of high-fidelity simulation (Abulfaraj et al., 2021; Plotsky et al., 2021).
Future Implications
Piloting the forthcoming PICC and midline catheter insertion VR scenarios is the next step in quantifying the impact of VR in vascular access education and training. Allowing subject-matter experts to beta test the VR vascular access curriculum will further refine the proposed simulation template and serve as a roadmap for longitudinal studies exploring different outcomes (e.g., procedural confidence, time-to-insertion, appropriate vascular access device selection, success rates, etc.).
To address stakeholder concerns related to cybersickness, simulationists must advocate for VR headsets that optimize interpupillary distance fit and reduce audio/visual latency. These headset technical capabilities are known to be superior in newer headset models. Other stakeholder considerations include IT systems and support, logistics and infrastructure, and leadership engagement (Stallo et al., 2024). Consumers should consider the following when deciding if VR is a viable option in their organization:
1. Is VR an appropriate modality for addressing your existing education and training gaps?
2. Are there any infrastructure limitations in your simulation center? (e.g., recommended space is 12’x12’ and must have good internet connectivity)
3. Does your budget permit the purchase of VR headsets and licenses? If not, have you considered grants, partnerships, donations, etc.?
4. Will your leadership support the potential need to hire/contract a VR implementation consultant?
The PICC and midline catheter insertion VR scenarios discussed in this work are the first of its kind. CLINSPEC Solutions is unbiased towards any developer and disclosed its partnership with SimX as an ethical consideration and not for marketing purposes. The key take-away is that immersive VR modalities have the potential to shape the future of vascular access specialist education and training when strategically implemented.
Conclusion
A well-designed VR vascular access curriculum that incorporates EBP guidelines, assessment methods, a debriefing plan, and program evaluation will be vital to the success of future vascular access education and training programs. Pilot testing this initiative will help guide future research efforts that aim to optimize and standardize vascular access clinical competencies worldwide. The benefits of VR use in vascular access training outweigh its haptic feedback limitations. In the meantime, mixed methods that combine traditional methods with immersive VR should be explored to offer the full experience.
References
Abich IV, J., Parker, J., Murphy, J. S., & Eudy, M. (2021). A review of the evidence for training effectiveness with virtual reality technology. Virtual Reality, 25(4), 919-933.
Abulfaraj, M. M., Jeffers, J. M., Tackett, S., & Chang, T. (2021). Virtual reality vs. high-fidelity mannequin-based simulation: a pilot randomized trial evaluating learner performance. Cureus, 13(8).
Bajaj, K., Meguerdichian, M., Thoma, B., Huang, S., Eppich, W., Cheng, A. (2018). The PEARLS Healthcare Debriefing Tool. Acad Med, 93(2), 336.
Chopra, V., O'Malley, M., Horowitz, J., Zhang, Q., McLaughlin, E., Saint, S., ... & Flanders, S. (2022). Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. BMJ quality & safety, 31(1), 23-30.
Coulter, K. (2022). Session 6: clinical theory, devices & placement. [Presentation]. Infusion Knowledge VA-BC Review Program.
CVC Healthcare LLC. (2022). Standards and recommendations. [Presentation]. PICC/midline insertion class: building vascular access teams and programs.
Dabadie, A., Soussan, J., Mancini, J., Vidal, V., Bartoli, J. M., Gorincour, G., & Petit, P. (2016). Development and initial evaluation of a training program for peripherally inserted central catheter (PICC) placement for radiology residents and technicians. Diagnostic and Interventional Imaging, 97(9), 877-882.
Frye, A. W., & Hemmer, P. A. (2012). Program evaluation models and related theories: AMEE guide no. 67. Medical teacher, 34(5), e288-e299.
iData Research. (2020, February 2). Over 2.7 Million PICC Line Insertion Procedures Are Performed Each Year in the US. iData Research. Retrieved from https://idataresearch.com/over-2-7-million-picc-line-insertion-procedures-are-performed-each-year-in-the-us/
Johnson, G. (2023). Incorporating technology in teaching: a current status overlook. Nursing Education: Accelerating Learning with Virtual Reality Simulations (pp. 11-14). Independently published.
Kardong-Edgren, S. S., Farra, S. L., Alinier, G., & Young, H. M. (2019). A call to unify definitions of virtual reality. Clinical simulation in nursing, 31, 28-34.
Kayingo, G., & Hass, V. M. (Eds.). (2017). The health professions educator: A practical guide for new and established faculty (pp. 199-203). Springer Publishing Company.
Kondrashova, T., Canaan, R., Gunn, B., Pazdernik, V., & Houser, J. J. (2020). Development of competency in needle-guided procedures through the use of soft-embalmed cadavers. Missouri Medicine, 117(5), 461.
Kyaw, B. M., Saxena, N., Posadzki, P., Vseteckova, J., Nikolaou, C. K., George, P. P., ... & Car, L. T. (2019). Virtual reality for health professions education: systematic review and meta-analysis by the digital health education collaboration. Journal of medical Internet research, 21(1), e12959.
Lie, S. S., Helle, N., Sletteland, N. V., Vikman, M. D., & Bonsaksen, T. (2023). Implementation of virtual reality in health professions education: scoping review. JMIR Medical Education, 9, e41589.
McKinsey & Company. (2023, May 5). Nursing in 2023. McKinsey & Company. Retrieved from https://www.mckinsey.com/industries/healthcare/our-insights/nursing-in-2023/
Nicolaus, S., Crelier, B., Donzé, J. D., & Aubert, C. E. (2022). Definition of patient complexity in adults: A narrative review. Journal of multimorbidity and comorbidity, 12, 26335565221081288. https://doi.org/10.1177/26335565221081288
Ostrowski, A. M., Morrison, S., & O'Donnell, J. (2019). Development of a Training Program in Peripherally Inserted Central Catheter Placement for Certified Registered Nurse Anesthetists Using an N-of-1 Method. AANA journal, 87(1).
Park, S., & Lee, G. (2020). Full-immersion virtual reality: Adverse effects related to static balance. Neuroscience letters, 733, 134974.
Plotzky, C., Lindwedel, U., Sorber, M., Loessl, B., König, P., Kunze, C., ... & Meng, M. (2021). Virtual reality simulations in nurse education: A systematic mapping review. Nurse education today, 101, 104868.
Pottle, J. (2019). Virtual reality and the transformation of medical education. Future healthcare journal, 6(3), 181.
Savir, S., Khan, A. A., Yunus, R. A., Rehman, T. A., Saeed, S., Sohail, M., ... & Matyal, R. (2023). Virtual Reality: The Future of Invasive Procedure Training?. Journal of Cardiothoracic and Vascular Anesthesia.
Siddaiah-Subramanya, M., Smith, S., & Lonie, J. (2017). Mastery learning: how is it helpful? An analytical review. Advances in medical education and practice, 269-275.
SimX VR. (2021). Features. Retrieved from https://www.simxvr.com/features/
Song, I. K., Kim, E. H., Lee, J. H., Jang, Y. E., Kim, H. S., & Kim, J. T. (2018). Seldinger vs modified Seldinger techniques for ultrasound-guided central venous catheterisation in neonates: a randomised controlled trial. British Journal of Anaesthesia, 121(6), 1332-1337.
Stallo, P.L., Kardong-Edgren, S., & Baumann, E.B. (2024). The Influence of Technological and Design Decision Factors on the Incidence of Cybersickness: A Systematic Review. [Manuscript in preparation]. Department of Health Professions Education. MGH Institute of Health Professions.
U.S. Bureau of Labor Statistics. (2023, September 6). Occupational Outlook Handbook: Registered Nurses. Retrieved from https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-1
Appendix 1: VR Simulation Template for Midline Insertion.
Virtual Reality Simulation Template (Vascular Access – Midline Insertion)
Introduction:
Welcome to an immersive journey through time and space as we transport you to the core of healthcare. In this virtual reality simulation, you will have the unique opportunity to apply what you have learned in your PICC/midline insertion training course. As you don your VR headset and step into the patient’s room, you will find yourself immersed in the clinical setting – ready to perform an advanced vascular access procedure, as appropriate. You will enter the patient’s room and systematically progress through the scenario as you would in real life.
This VR simulation is not just a game; it is an educational journey that promises to ignite your curiosity, immerse you in patient care, and promote critical thinking. So, get ready to make a difference!
Training Space: This VR scenario is intended to be used by accredited PICC/midline training programs to evaluate learner performance.
Headset: Universal, wireless (Oculus, Apple, etc.)
Case Specification:
· Case Name: Establishing vascular access in a difficult venous access patient
· Case Language: English
· Author: Dagoberto Salinas
· Learner Population: Registered nurses and healthcare providers
· Room Size Recommendation: 15’ x 15’
· Basic Case Overview:
A 67-year-old male is recovering (hospital day #4) in the intensive care unit (ICU) after being treated for sepsis, secondary to bacterial pneumonia. Four days ago, the patient presented to the ER with signs and symptoms of respiratory failure, including rales and decreased breath sounds over lung bases bilaterally. Chest x-ray showed significant consolidation in the superior segments of the left and right lower lobes. The patient’s deteriorating medical condition led to endotracheal intubation, central line placement (non-tunneled, triple-lumen catheter in the right subclavian vein), and administration of intravenous sedation and vasopressors.
During interdisciplinary rounds in the ICU on hospital day #4, the team confirmed that the patient’s clinical status had improved and they no longer required mechanical ventilation or vasopressors. The interdisciplinary team agreed to discontinue central line access upon obtaining a reliable peripheral venous access device (per facility’s central venous catheter maintenance bundle guidelines). After four failed attempts to obtain a peripheral IV by ICU staff, the vascular access team was consulted for further evaluation. It was noted through ultrasound visualization that the patient had limited peripheral venous access, making it difficult to insert a standard peripheral IV. After completing the venous access evaluation, the vascular team recommended placement of a midline catheter considering the patient’s difficult intravenous access history and need to maintain vascular access for six more days for completion of prescribed antibiotic regimen (IV ceftriaxone and azithromycin).
· Moderator Visible Case Description:
A 67-year-old male with recent diagnosis of septic shock secondary to pneumonia is now recovering and no longer in need of central venous access. Unfortunately, the nursing staff were unable to establish peripheral IV access after several attempts. The learner will evaluate the patient, review medical history, and establish vascular access using the appropriate technique.
· Learning Objectives/Critical Actions:
o After participating in the VR scenario, learners will be able to:
v State two clinical indications for midline placement§ The learner will have to identify the appropriate vascular access device to use for insertion based on the clinical scenario provided (e.g., PICC vs midline vs peripheral IV)
v Identify the three appropriate vein site locations for midline placement
§ The learner scans anatomical sites on the upper arm with ultrasound to identify appropriate veins (basilic, brachial, or cephalic veins)
v State three potential contraindications for midline placement
v Demonstrate correct sequence for obtaining vascular access using Seldinger’s technique
§ The learner will systematically insert the midline catheter per manufacturer’s recommendations
v Document with 100% accuracy all pre-procedural, procedural, and post-procedural interventions, per The Joint Commission standards for documentation
§ The learner will need to indicate that documentation has been completed
Pre-briefing:
· Pre-briefing will be performed in real time by the moderator in person and will include the following elements:
o Orientation to both physical and VR environments, including VR controls
o Expectations related to learners’ involvement and performance
o Length of scenario
o Moderator’s role in facilitating during VR scenario
· Link curricular objectives to safety/organizational/practice standards:
Environment:
· VR setting is programmed with vascular access equipment/supplies (e.g., hospital bed, PICC/midline supply cart, bedside table, ultrasound machine, etc.)
Tools:
· Midline insertion kit
· Ultrasound machine
· Supply Cart
· Bedside Table
Patient(s):
· Age
· Gender
· General appearance
· Medical specifications
· Patient case notes
· Starting position
· Dialogue
Other Characters:
· Character type in VR environment: Family members, medical staff (RN, RN assist, lab tech, x-ray tech, telephone operator), or other characters with in-person speaking or action roles important to the simulation. The nurse assistant will be played by another vascular access student, and then roles will be reversed so that each student participates as both an inserter and assistant.
· Age
· Gender
· Relationship to patient
· General appearance
· Expected actions character should be able to perform
· Dialogue
Electronic Medical Record:
· General EMR information
o Name
o Age/DOB
o Gender
o Weight
o Language
o ID#
o Chief complaint
o History of present illness
o Medications
o Allergies:
o Labs:
o Past Medical History:
o Past Surgical History:
o Family History
o Social History:
o Admission Diagnosis
o Admission Department
o Hospital Day #
o Lab results
o Imaging results
Case Flow:
· Once the moderator presses the “Start Case” button, the case will progress sequentially through the states (milestones) as the learner completes all the necessary steps for completing the skill. At any point, the moderator can choose to advance to the next state by pressing the “Advance State” button. Learners cannot return to the previous state if mastery has already been achieved. Learners must advance forward once a milestone has been completed.
o Every case should have a “Start Scenario” state without any critical actions or dialogue. Only a “Start Case” moderator button will be available on the moderator’s screen. This allows all headset users to load in before starting the actual scenario.