1. Reducing Complications of Central Venous Catheter Insertion

    Most Intensive Care Units (ICU) collect comprehensive data relating to patient demographics, diagnoses and complications and some use this information to benchmark and guide quality improvement activities aimed at improving patient outcomes and reducing iatrogenic complications. Ayas et. al. are to be commended for using routine information they collect in an attempt to identify trends and possible contributing factors to one of the potential complications related to insertion of Central Venous Catheters (CVCs), development of a pneumothorax. Their retrospective review did not confirm their suspicions that the incidence of pneumothorax would increase with the introduction of new trainees to their area, which is surprising, however they have suggested that decreased supervision as the ICU rotation progresses may contribute to this. CVCs are widely used in ICUs around the world, and pneumothoraces are a significant potential complication of insertion of CVCs into the internal jugular and subclavian veins (SCV). There is high level evidence to support the insertion of CVCs into neck veins, particularly the SCV, as opposed to femoral veins to reduce the incidence of blood stream infections that contribute to significant morbidity and mortality, and increased length and cost of hospital stay.1 Sheretz et. al. demonstrated that providing targeted training for physicians in relation to methods to reduce infection related to vascular device insertion resulted in improved knowledge and retention that translated into practice. In their study, compliance with evidence based procedures improved and resulted in a reduction in the incidence of CVC bloodstream infections. They provided a detailed cost-benefit analysis of their training program that supports such an approach to improving quality and safety of patient care.2 Ault described an approach to training inexperienced practitioners that used tissue models for practice, the use of ultrasound devices, a focus on use of large drapes and improved sharps handling that resulted in improved accuracy and safety of CVC insertion.3 Ayas et. al. refer to the use of ultrasound guidance to assist in CVC placement as being sporadic in their study settings, which could contribute to the trends they are identifying, however the evidence to support the routine use of such devices is to date not strong.4 The only training method referred to by Ayas et. al. is supervision by more experienced practitioners in the clinical field. Perhaps they could consider introducing more formalized training, as described above, to reduce the incidence of pneumothorax and other complications related to CVC insertion for their patients. The routine data they are currently collecting could assist in assessing the efficacy of such an approach. Ros MacLeod, BN, Grad Cert CCN, Grad Dip Nursing, Nurse Unit Manager, ICU, Western Health, Footscray, Australia, References: 1. O’Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J.L., Heard, S. O., Maki, D. G., Maur, H., McCormick, R. D., Mermel. L.A., Person, M. L., Raad, I. I., Randolph, A., Weinstein., R. A.. Guidelines for the Prevention of Intravascular Catheter-Related Infections. National Center for Infectious Diseases. 2002. 2. Sherertz, R. J., Ely, E., Wesley M. D., Westbrook, D. M., RN, Gledhill, K. S., Streed, S. A., Kiger, B., Flynn, L., Hayes, S., Strong, S., Cruz, J., Bowton, D. L., Hulgan, T. & Haponik, E. Education of Physicians-in -Training Can Decrease the Risk for Vascular Catheter Infection. Annals of Internal Medicine: 2000: 132(8): 641-648. 3. Ault, M. J. The Use of Tissue Models for Vascular Access Training: Phase 1 of the Procedural Safety Initiative. Academic Emergency Medicine. 2007: 14(1):13. 4. Stone, M.B. Identification and correction guide wire malposition during internal jugular cannulation with ultrasound. Journal of the Canadian Association of Emergency Physicians. 2007:p(2):131.

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