Is Routine Chest X-Ray After Ultrasound-Guided Central Venous Catheter Insertion Choosing Wisely?

IntroductionAvoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention.MethodsThe intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan’s framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor’s outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion.With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments.Ethics and disseminationApproval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means.Trial registration numberClinicalTrials.gov Identifier, NCT04324762, registered on 27 March 2020.

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Pre- and post-review of a standardized ultrasound-guided central venous catheterization curriculum evaluating procedural skills acquisition and clinician confidence

The Journal of Vascular Access ◽

10.1177/1129729819882602 ◽

2019 ◽

Vol 21 (4) ◽

pp. 440-448 ◽

Cited By ~ 1

Author(s):

Timothy R Spencer ◽

Amy J Bardin-Spencer

Keyword(s):

Central Venous Catheter ◽

Central Venous Catheterization ◽

Venous Catheter ◽

Catheter Insertion ◽

Central Venous Catheter Insertion ◽

Ultrasound Guided ◽

Central Venous ◽

Clinical Simulation ◽

Venous Catheterization ◽

Simulation Based

Background: To evaluate novice and expert clinicians’ procedural confidence utilizing a blended learning mixed fidelity simulation model when applying a standardized ultrasound-guided central venous catheterization curriculum. Methods: Simulation-based education and ultrasound-guided central venous catheter insertion aims to provide facility-wide efficiencies and improves patient safety through interdisciplinary collaboration. The objective of this quality improvement research was to evaluate both novice (<50) and expert (>50) clinicians’ confidence across 100 ultrasound-guided central venous catheter insertion courses were performed at a mixture of teaching and non-teaching hospitals across 26 states within the United States between April 2015 and April 2016. A total of 1238 attendees completed a pre- and post-survey after attending a mixed method clinical simulation course. Attendees completed a 4-h online didactic education module followed by 4 h of hands-on clinical simulation stations (compliance/sterile technique, needling techniques, vascular ultrasound assessment, and experiential complication management). Results: The use of a standardized evidence-based ultrasound-guided central venous catheter curriculum improved confidence and application to required clinical tasks and knowledge across all interdisciplinary specialties, regardless of level of experience. Both physician and non-physician groups resulted in statistically significant results in both procedural compliance ( p < 0.001) and ultrasound skills ( p < 0.001). Conclusion: The use of a standardized clinical simulation curriculum enhanced all aspects of ultrasound-guided central venous catheter insertion skills, knowledge, and improved confidence for all clinician types. Self-reported complications were reported at significantly higher rates than previously published evidence, demonstrating the need for ongoing procedural competencies. While there are growing benefits for the role of simulation-based programs, further evaluation is needed to explore its effectiveness in changing the quality of clinical outcomes within the healthcare setting.

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