Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion

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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Study Protocol for Draup: De-implementation Ofroutine Chest Radiographs After Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol, A Hybrid Implementation/effectiveness Study

10.21203/rs.3.rs-37859/v1 ◽

2020 ◽

Author(s):

Enyo A. Ablordeppey ◽

Byron J. Powell ◽

Virginia R. McKay ◽

Shannon M. Keating ◽

Aimee S. James ◽

...

Keyword(s):

Central Venous Catheter ◽

Focus Groups ◽

Imaging Modality ◽

Point Of Care ◽

Implementation Strategies ◽

Venous Catheter ◽

Point Of Care Ultrasound ◽

Central Venous ◽

Medical Overuse ◽

Chest X Ray

Abstract BACKGROUNDAvoiding low value medical practices is an important focus in current healthcare utilization. Despite advantages of point of care ultrasound (POCUS) over chest x-ray (CXR), including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation and exclusion of pneumothorax (PCEP) has had slow rate of adoption. This demonstrates a gap that is ripe for the development and application of de-implementation strategies that support substitution of POCUS for CXR after CVC insertion.METHODSDe-implementation of routine chest radiographs after adoption of ultrasound guided insertion and confirmation of central venous catheter protocol (DRAUP) will be created to de-implement an unnecessary imaging modality in the critical care environment. Guided by the Consolidated Framework for Implementation Research constructs, we will explore barriers and facilitators of POCUS for CVC PCEP in a single center, large tertiary, academic hospital via focus groups. The focus groups will inform the development and testing of strategies that address identified determinants of implementation and de-implementation.Operational use of the de-implementation strategies will be conceptualized using Morgan’s framework for understanding and reducing medical overuse. We will locally implement these strategies and assess them using Proctor’s outcomes (adoption, de-adoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on our selected implementation and de-implementation strategies. Secondary outcomes will include POCUS-guided CVC PCEP efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS detection.DISCUSSIONWith limited data available to inform interventions that use concurrent implementation and de-implementation strategies to substitute CXR for POCUS using DRAUP, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that would expand the knowledge of replacing low value or unnecessary care in critically ill patients. Trial Registration: ClinicalTrials.gov Identifier, NCT04324762, Registered on 27 March 2020

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Optimal prediction of the central venous catheter insertion depth on a routine chest x-ray

Nutrition ◽

10.1016/j.nut.2010.07.005 ◽

2011 ◽

Vol 27 (5) ◽

pp. 557-560 ◽

Cited By ~ 9

Author(s):

Yumiko Uchida ◽

Masaki Sakamoto ◽

Hiroki Takahashi ◽

Yoichi Matsuo ◽

Hitoshi Funahashi ◽

...

Keyword(s):

Central Venous Catheter ◽

Venous Catheter ◽

Catheter Insertion ◽

Central Venous Catheter Insertion ◽

Optimal Prediction ◽

Central Venous ◽

Insertion Depth ◽

X Ray ◽

Chest X Ray ◽

Routine Chest

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

CHEST Journal ◽

10.1016/j.chest.2018.02.017 ◽

2018 ◽

Vol 154 (1) ◽

pp. 148-156 ◽

Cited By ~ 16

Author(s):

Jason Chui ◽

Rasha Saeed ◽

Luke Jakobowski ◽

Wanyu Wang ◽

Basem Eldeyasty ◽

...

Keyword(s):

Central Venous Catheter ◽

Venous Catheter ◽

Catheter Insertion ◽

Choosing Wisely ◽

Central Venous Catheter Insertion ◽

Ultrasound Guided ◽

Central Venous ◽

X Ray ◽

Chest X Ray ◽

Routine Chest

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Contrast enhanced ultrasound vs chest X-ray to determine correct central venous catheter position

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2013.10.001 ◽

2014 ◽

Vol 32 (1) ◽

pp. 78-81 ◽

Cited By ~ 21

Author(s):

Francesca Cortellaro ◽

Luca Mellace ◽

Stefano Paglia ◽

Giorgio Costantino ◽

Sara Sher ◽

...

Keyword(s):

Central Venous Catheter ◽

Venous Catheter ◽

Contrast Enhanced Ultrasound ◽

Central Venous ◽

Catheter Position ◽

X Ray ◽

Contrast Enhanced ◽

Chest X Ray

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Is chest X-ray still necessary after central venous catheter insertion?*

Critical Care Medicine ◽

10.1097/ccm.0b013e3181bfeb45 ◽

2010 ◽

Vol 38 (2) ◽

pp. 715-716 ◽

Cited By ~ 6

Author(s):

Christine Ammirati ◽

Julien Maizel ◽

Michel Slama

Keyword(s):

Central Venous Catheter ◽

Venous Catheter ◽

Catheter Insertion ◽

Central Venous Catheter Insertion ◽

Central Venous ◽

X Ray ◽

Chest X Ray

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Ultrasound to Detect Central Venous Catheter Placement Associated Complications

Anesthesiology ◽

10.1097/aln.0000000000003126 ◽

2020 ◽

Vol 132 (4) ◽

pp. 781-794 ◽

Cited By ~ 1

Author(s):

Jasper M. Smit ◽

Mark E. Haaksma ◽

Endry H. T. Lim ◽

Thei S. Steenvoorden ◽

Michiel J. Blans ◽

...

Keyword(s):

Central Venous Catheter ◽

Diagnostic Accuracy ◽

Central Venous Catheterization ◽

Venous Catheter ◽

Reference Standard ◽

Central Venous ◽

Central Venous Catheter Placement ◽

X Ray ◽

Venous Catheterization ◽

Chest X Ray

Abstract Background Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect pneumothorax, chest x-ray film has been the reference standard, while ultrasound might be an accurate alternative. The aim of this study was to evaluate diagnostic accuracy of ultrasound to detect central venous catheter malposition and pneumothorax. Methods This was a prospective, multicenter, diagnostic accuracy study conducted at the intensive care unit and postanesthesia care unit. Adult patients who underwent central venous catheterization of the internal jugular vein or subclavian vein were included. Index test consisted of venous, cardiac, and lung ultrasound. Standard reference test was chest x-ray film. Primary outcome was diagnostic accuracy of ultrasound to detect malposition and pneumothorax; for malposition, sensitivity, specificity, and other accuracy parameters were estimated. For pneumothorax, because chest x-ray film is an inaccurate reference standard to diagnose it, agreement and Cohen’s κ-coefficient were determined. Secondary outcomes were accuracy of ultrasound to detect clinically relevant complications and feasibility of ultrasound. Results In total, 758 central venous catheterizations were included. Malposition occurred in 23 (3.3%) out of 688 cases included in the analysis. Ultrasound sensitivity was 0.70 (95% CI, 0.49 to 0.86) and specificity 0.99 (95% CI, 0.98 to 1.00). Pneumothorax occurred in 5 (0.7%) to 11 (1.5%) out of 756 cases according to chest x-ray film and ultrasound, respectively. In 748 out of 756 cases (98.9%), there was agreement between ultrasound and chest x-ray film with a Cohen’s κ-coefficient of 0.50 (95% CI, 0.19 to 0.80). Conclusions This multicenter study shows that the complication rate of central venous catheterization is low and that ultrasound produces a moderate sensitivity and high specificity to detect malposition. There is moderate agreement with chest x-ray film for pneumothorax. In conclusion, ultrasound is an accurate diagnostic modality to detect malposition and pneumothorax. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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