Impact of the simulation-based Airway and Catheter Cannulation Education—from Starters to Specialists (ACCESS) program for critical care procedures

Abstract

Purpose

Central venous catheterization and endotracheal intubation are critical lifesaving procedures, yet structured training opportunities remain limited and often rely on informal apprenticeships. This study evaluates the effectiveness of the Airway and Catheter Cannulation Education—from Starters to Specialists (ACCESS) program in improving procedural knowledge, confidence, and ultrasound proficiency.

Methods

Data from 70 healthcare professionals (38 residents, 28 specialists, and 4 others) who completed the ACCESS program between 2022 and 2025 were analyzed. Participants were divided into two cohorts: a retrospective cohort (n=46) from 2022 to 2023, who completed the post-training questionnaire only, and a prospective cohort (n=24) from 2024 to 2025, who underwent pre- and post-training assessments. The questionnaire used a self-reported 10-point Likert scale.

Results

Overall, 67 valid post-training responses were analyzed, excluding 3 incomplete surveys from the prospective group. Participants reported exceptional satisfaction, with clinicians (>6 years of experience) reporting higher satisfaction with equipment (P=0.020). In the prospective cohort (pre-training, n=24; post-training, n=21), significant improvements were observed across all domains (P<0.001). Ultrasound proficiency showed the most dramatic increase (from 4.67 to 8.81), accompanied by marked improvements in procedural confidence.

Conclusions

The ACCESS program effectively enhanced procedural competence, especially ultrasound-guided skills. The significant improvement observed in the cohort with a high percentage of specialists underscores the limitations of traditional models and highlights the critical value of standardized high-fidelity simulation training programs for physicians at all career stages.

INTRODUCTION

Background

Central venous catheterization (CVC) and endotracheal intubation are core procedures in critical care and trauma resuscitation. Proficiency in these skills is mandatory for surgeons, emergency physicians, and other specialists managing critically ill patients. With the increased adoption of standards of care, ultrasound-guided techniques are now strongly recommended to reduce complications such as arterial puncture, pneumothorax, and catheter-related bloodstream infections [1,2].

Despite the critical nature of these skills, achieving competency through the traditional apprenticeship model, in which junior trainees learn from senior residents or attending physicians, has become increasingly untenable. Restricted resident duty hours and heightened scrutiny of patient safety have significantly limited opportunities for direct clinical exposure [3]. Consequently, recent studies indicate that many residents complete training without achieving sufficient comfort or proficiency in procedural skills [4]. Moreover, the absence of a standardized, validated curriculum that can be universally implemented further exacerbates variability in training quality and clinical readiness.

Simulation-based training has emerged as a robust educational strategy to address these gaps. Simulation-based training allows deliberate practice in a risk-free environment, facilitating the acquisition of complex psychomotor skills without compromising patient safety [5]. Extensive evidence demonstrates that simulation-based training improves procedural confidence and success rates and significantly reduces catheter-related bloodstream infections and mechanical complications in clinical practice [6–8].

Although simulation-based training is effective, many existing programs focus solely on residents or specific specialties. There is a growing need for a comprehensive curriculum that serves diverse learners, from novices building initial competence to specialists refining their knowledge and ultrasound-guided techniques. In trauma centers and intensive care units, where rapid and accurate vascular access and airway management are pivotal for patient survival, ensuring proficiency across staff levels is crucial.

Objectives

This study evaluates the effectiveness of the Airway and Catheter Cannulation Education—from Starters to Specialists (ACCESS) program, a structured, simulation-based course designed to bridge competency gaps for physicians at all career stages.

METHODS

Ethics statement

This study was approved by the Institutional Review Board of Dankook University Hospital (No. DKUH 2026-01-003). Informed consent was waived because the survey was anonymous and did not collect identifiable participant information.

Study design and participants

The study population comprised 70 healthcare professionals, including 69 physicians (residents, specialists, and general practitioners) and one nurse practitioner, who completed the ACCESS program between 2022 and 2025. The nurse practitioner was included in the analysis because their baseline procedural experience was comparable to that of junior physicians, safely aligning with the “starter” demographic of the program without compromising the homogeneity of the data. A mixed-methods approach was used, combining a retrospective analysis of accumulated data with a prospective cohort study. The initial phase (2022–2023) was conducted retrospectively, reviewing data from 46 participants who completed only the post-training questionnaire, with a primary focus on program satisfaction. A prospective cohort of 24 participants was recruited in the second phase (2024–2025) to more rigorously evaluate educational efficacy. Unlike the retrospective group, the prospective cohort completed both pre- and post-training assessments to quantitatively measure changes in procedural competency. Consequently, 67 valid responses were included in the overall assessment with 21 in the prospective cohort analysis, as 3 participants did not complete the post-training survey.

Educational intervention

The ACCESS program is an intensive, 1-day, simulation-based curriculum designed to enhance proficiency in essential critical care procedures. It was established to address gaps in procedural training in Korea by providing a rare opportunity for physicians to engage in high-level simulation training. The curriculum comprises didactic instruction followed by hands-on simulation with immediate expert feedback (Fig. 1). First, evidence-based didactic lectures provide a comprehensive review of anatomy, procedural sequences, clinical pearls, and potential complications associated with CVCs and endotracheal intubation [9–15]. Participants then rotate through practical skill stations equipped with high-fidelity, ultrasound-compatible simulators that allow practice in CVC (internal jugular, subclavian, femoral), peripherally inserted central catheters, midline catheters, and intraosseous injections. Airway management stations are similarly equipped for advanced procedures such as video laryngoscopy and percutaneous dilatational tracheostomy. Under the supervision of experienced trauma surgeons and critical care specialists affiliated with regional trauma centers, all of whom are certified instructors with extensive clinical experience in trauma resuscitation, participants receive immediate feedback to refine their skills in this advanced simulation-based environment.

Fig. 1.

Overview of the Airway and Catheter Cannulation Education—from Starters to Specialists (ACCESS) program curriculum and simulation equipment. (A) Curriculum timetable illustrating the intensive 1-day schedule, comprising didactic lectures followed by hands-on simulation sessions. (B) Photographs of the high-fidelity task trainers used in the workshop. ^a)The allocated time for each procedure is written in Korean, which translates to “23 minutes per procedure, 10-minute break after completing three procedures.”

Data collection

Data were collected using anonymous, self-administered questionnaires to ensure confidentiality and honest reporting. The survey captured baseline demographic characteristics, including professional position, specialty, years of experience, and procedural frequency. Program evaluation included participant satisfaction with lectures, simulation equipment, and overall course quality, assessed using a 10-point Likert scale. For the prospective cohort, pre- and post-training assessments evaluated the educational impact on procedural knowledge, confidence, and technical proficiency, with particular emphasis on ultrasound utilization. Because the survey maintained strict anonymity, individual identifiers were not collected, precluding matched pre- and post-training responses for the same participants.

Statistical analysis

Continuous variables were expressed as means with standard deviations, and categorical variables, including demographic characteristics, were presented as frequencies and percentages. To assess the impact of clinical experience and professional position on program satisfaction, independent t-tests were utilized to compare mean scores between subgroups (e.g., specialists versus nonspecialists, and participants with ≤6 years vs. >6 years of clinical experience). For the prospective cohort, training efficacy was evaluated by comparing pre- and post-training scores. Because anonymity prevented individual-level matching, independent t-tests were used to compare differences in mean scores between the pre-training (n=24) and post-training (n=21) groups. All statistical analyses were conducted using R ver. 4.5.1 (R Foundation for Statistical Computing). Statistical significance was set at P<0.05.

RESULTS

A total of 70 physicians participated in the ACCESS program between 2022 and 2025 (Table 1). The cohort consisted of 38 residents (54.3%), 28 specialists (40.0%), and 4 others (5.7%, three general practitioners and one nurse practitioner). Participants represented diverse specialties, with surgery (22.9%) and emergency medicine (17.1%) being the most common, followed by internal medicine and neurosurgery (both 14.3%). Of the participants, 52 (74.3%) had less than 6 years of clinical experience. A significant proportion also reported low procedural frequency for both CVCs and endotracheal intubation.

Table 1.

Overall participant characteristics (n=70)

Characteristic	No. of participants (%)
Position
Specialist	28 (40.0)
Resident	38 (54.3)
General practitioner/nurse practitioner	4 (5.7)
Specialty
Surgery	16 (22.9)
Emergency medicine	12 (17.1)
Internal medicine	10 (14.3)
Neurosurgery	10 (14.3)
Neurology	3 (4.3)
Anesthesiology	3 (4.3)
Pediatrics	3 (4.3)
Family medicine	3 (4.3)
Oral and maxillofacial surgery	2 (2.8)
Othera)	8 (11.4)
Clinical experience
>10 yr	13 (18.6)
7–9 yr	5 (7.1)
4–6 yr	12 (17.1)
1–3 yr	31 (44.3)
<1 yr	9 (12.9)
CVC experience
≥5 cases per month	20 (28.6)
<5 cases per month	11 (15.7)
<5 cases per 6 months	14 (20.0)
<5 cases per year	25 (35.7)
Intubation experience (n=69)
≥5 cases per month	19 (27.5)
<5 cases per month	13 (18.9)
<5 cases per 6 months	19 (27.5)
<5 cases per year	18 (26.1)

CVC, central venous catheter.

^a)One urology, one plastic surgery, one rehabilitation medicine, three general practitioners, and one nurse practitioner.

Program evaluation revealed high overall satisfaction scores across all domains (Table 2). Among the 67 valid responses, the mean willingness-to-recommend score was 9.78±0.57. Participants also reported high satisfaction with acquiring new knowledge (9.64±0.79). Subgroup analysis based on clinical experience (≤6 years vs. >6 years) demonstrated notable patterns. Although no significant differences were observed in perceived course difficulty (P=0.139) or lecture satisfaction (P=0.257), experienced clinicians reported significantly higher equipment satisfaction (9.65±0.61 vs. 9.08±1.31, P=0.020). Their willingness to recommend the program was also significantly higher (9.94±0.24 vs. 9.72±0.64, P=0.045).

Table 2.

Self-reported scores after the ACCESS program

Domain	Overall (n=67)	Clinical experience		P-value
		≤6 yr (n=50)	>6 yr (n=17)
Course difficulty	9.49±0.82	9.42±0.88	9.71±0.59	0.139
Course duration	8.93±1.55	8.92±1.60	8.94±1.43	0.960
Equipment satisfaction	9.22±1.19	9.08±1.31	9.65±0.61	0.020
Lecture satisfaction	9.55±0.72	9.50±0.76	9.71±0.59	0.257
New knowledge	9.64±0.79	9.70±0.68	9.47 ±1.07	0.416
Recommendation	9.78±0.57	9.72±0.64	9.94±0.24	0.045
Pre-video satisfaction	9.43±1.08	9.38±1.18	9.59±0.71	0.390

Values are presented as mean±standard deviation.

ACCESS, Airway and Catheter Cannulation Education—from Starters to Specialists.

The prospective cohort included 13 specialists (54.2%), 8 residents (33.3%), and 3 others (12.5%, two general practitioners and one nurse practitioner). Notably, nine participants (37.5%) had more than 10 years of clinical experience. In terms of prior training, 19 participants (79.1%) had been trained by seniors or peers, 1 (4.2%) through self-study, and 4 (16.7%) had no prior training. Fig. 2 shows the educational impact of the ACCESS program in this cohort. At baseline, the mean self-reported score for ultrasound skills was the lowest among all domains (4.67±3.02), reflecting low confidence in ultrasound-guided techniques. After the intervention, statistically significant improvements were observed across all five domains (P<0.001). Ultrasound skill scores nearly doubled, increasing to 8.81±1.25.

Fig. 2.

Comparison of self-reported competency scores before and after the Airway and Catheter Cannulation Education—from Starters to Specialists (ACCESS) program. The graph illustrates significant improvements in procedural knowledge, confidence, and technical proficiency in the prospective cohort (pre-training, n=24 vs. post-training, n=21). All five domains showed statistically significant increases (P<0.001). CVC, central venous catheterization.

DISCUSSION

This study demonstrated that the ACCESS program was highly effective in improving procedural competence in CVCs and endotracheal intubation. The most significant finding was the substantial improvement in ultrasound proficiency and procedural confidence across all participants, including specialists. Additionally, among the 67 participants, satisfaction with simulation training was uniformly high regardless of professional position, with experienced clinicians expressing significantly higher satisfaction with the equipment.

A key observation in the prospective cohort was the low baseline score for ultrasound skills, despite 37.5% of participants having more than 10 years of clinical experience. This discrepancy highlights a generational gap in medical training. Although ultrasound-guided CVC has been recommended as the standard of care [1,6], many senior physicians were trained during the landmark-guided era and may not have received formal instruction in ultrasound-guided techniques. These results corroborate the findings of Chow et al. [4], who noted a lack of validated curricula for CVC training. The ACCESS program effectively bridged this gap by providing a safe, low-stakes environment in which clinicians could master contemporary ultrasound-guided techniques. This significant improvement underscores that high-fidelity simulation is not merely an introductory tool for “starters,” but a vital platform for re-skilling senior clinicians. Updating the competencies of experienced specialists who were trained before the ultrasound-guided era is one of the most critical contributions of such programs.

This study found no significant differences in overall satisfaction between residents and specialists, suggesting that the ACCESS curriculum meets diverse learning needs across the “from starters to specialists” spectrum. For residents, the program offers essential opportunities for deliberate practice, which are often constrained by duty hour restrictions [3]. For specialists, it provides a structured setting to refine skills and update safety protocols. This finding aligns with studies by Chang et al. [16] and Chang et al. [17] on the resuscitative endovascular balloon occlusion of the aorta (REBOA) training, which demonstrated that simulation courses benefit both residents and specialists by mitigating the learning curve associated with infrequent but critical procedures.

Most participants reported having received prior CVC training, primarily through peer instruction. Notably, participants with more than 6 years of clinical experience assigned significantly higher ratings for equipment satisfaction and program recommendation. Although this finding may appear counterintuitive, it likely reflects expert validation. More experienced clinicians, who are familiar with anatomical variability in real patients, may better appreciate the fidelity of the task trainers used in ACCESS. Their endorsement underscores that high-fidelity simulation is not solely an educational tool for novices but is also essential for maintaining competency and facilitating peer education among senior staff. This observation is consistent with findings by Cartier et al. [18], who reported significant improvements in both short- and long-term competence following simulation-based CVC education, and further supports evidence advocating multimodal simulation programs for enhancing competence, engagement, and perceived value [5,6,19].

These findings also align with a meta-analysis by Sun et al. [20], which concluded that simulation-based training is more effective than traditional methods for improving knowledge and psychomotor skills in airway management. Despite the brevity of the training, the improvements observed in this cohort suggest that even short-term, focused programs can yield meaningful gains in readiness to perform critical procedures.

Limitations

This study had several limitations. First, generalizability may be limited by the small sample size and heterogeneity of participants. Second, competency was assessed using self-reported confidence rather than objective checklists or clinical outcomes. Although self-efficacy is a strong predictor of performance, it does not necessarily translate directly into clinical technical success. To mitigate this self-reported bias, future studies should incorporate objective assessment tools, such as Objective Structured Clinical Examinations (OSCE) [21,22] or Global Rating Scales (GRS) [23,24], and track long-term clinical outcomes including procedural success and complication rates in actual practice. Furthermore, the exceptionally high satisfaction scores obtained immediately after the course must be interpreted with caution, as they may be influenced by a “halo effect” or courtesy bias inherent to post-training surveys. Third, because surveys were anonymous, paired t-tests could not be performed for the prospective cohort, necessitating the use of independent samples comparisons. Finally, long-term retention of skills was not evaluated. As a single simulation session is often insufficient for long-term skill retention, ongoing and repeated training is crucial, particularly for infrequent but lifesaving procedures. Future studies with longitudinal data are required to confirm the impact of repeated training sessions on sustained skill improvement. Given existing literature regarding psychomotor skill decay, a retraining interval of 6 to 12 months is recommended to maintain procedural competency [25,26].

Conclusions

The ACCESS program effectively standardized procedural training and significantly enhanced confidence and ultrasound proficiency. By addressing the distinct learning needs of both novices and experts, the program underscores the importance of simulation-based education as a lifelong learning tool. Broader implementation of such structured curricula may contribute to improved patient safety and clinical excellence in critical care and trauma resuscitation.