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

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

BMJ Open Quality ◽

10.1136/bmjoq-2020-001222 ◽

2021 ◽

Vol 10 (4) ◽

pp. e001222

Author(s):

Enyo A Ablordeppey ◽

Byron Powell ◽

Virginia McKay ◽

Shannon Keating ◽

Aimee James ◽

...

Keyword(s):

Central Venous Catheter ◽

Acute Care ◽

Imaging Modality ◽

Phase 1 ◽

Venous Catheter ◽

Point Of Care Ultrasound ◽

Central Venous ◽

X Ray ◽

Chest X Ray ◽

Routine Chest

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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Point of care ultrasound: Central venous catheter positioning and pneumothorax search

Journal of Critical Care ◽

10.1016/j.jcrc.2017.09.138 ◽

2017 ◽

Vol 42 ◽

pp. 413

Author(s):

Alejandro Enrique Barba Rodas ◽

Alexandre Francisco Silva ◽

Ana Beatriz Sorbile Veiga Ancora da Luz

Keyword(s):

Central Venous Catheter ◽

Point Of Care ◽

Venous Catheter ◽

Point Of Care Ultrasound ◽

Central Venous

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Point‐of‐care Ultrasound–guided Central Venous Catheter Confirmation in Ultrasound Nonexperts

AEM Education and Training ◽

10.1002/aet2.10530 ◽

2020 ◽

Author(s):

Enyo A. Ablordeppey ◽

Anne M. Drewry ◽

Adam L. Anderson ◽

Diego Casali ◽

Laura A. Wallace ◽

...

Keyword(s):

Central Venous Catheter ◽

Point Of Care ◽

Venous Catheter ◽

Point Of Care Ultrasound ◽

Ultrasound Guided ◽

Central Venous

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Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis

The Journal of Vascular Access ◽

10.1177/1129729820913437 ◽

2020 ◽

Vol 21 (6) ◽

pp. 923-930

Author(s):

George N Coritsidis ◽

Orlando N Machado ◽

Farzin Levi-Haim ◽

Sean Yaphe ◽

Roshan A Patel ◽

...

Keyword(s):

Central Venous Catheter ◽

Arteriovenous Fistula ◽

Point Of Care ◽

Demographic Data ◽

Venous Catheter ◽

Fisher Exact Test ◽

Point Of Care Ultrasound ◽

Central Venous ◽

Exact Test ◽

Central Venous Catheter Removal

Background: Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise. Methods: Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis. Results: A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound. Conclusion: Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.

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Use of Point-of-Care Ultrasound to Confirm Central Venous Catheter Placement and Evaluate for Postprocedural Complications

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2021.01.032 ◽

2021 ◽

Author(s):

Tim Montrief ◽

Jonathan Auerbach ◽

Jorge Cabrera ◽

Brit Long

Keyword(s):

Central Venous Catheter ◽

Point Of Care ◽

Venous Catheter ◽

Catheter Placement ◽

Point Of Care Ultrasound ◽

Central Venous ◽

Central Venous Catheter Placement

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Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound

Shock ◽

10.1097/shk.0000000000001218 ◽

2019 ◽

Vol 51 (5) ◽

pp. 613-618 ◽

Cited By ~ 5

Author(s):

Enyo A. Ablordeppey ◽

Anne M. Drewry ◽

Daniel L. Theodoro ◽

LinLin Tian ◽

Brian M. Fuller ◽

...

Keyword(s):

Central Venous Catheter ◽

Point Of Care ◽

Venous Catheter ◽

Point Of Care Ultrasound ◽

Central Venous ◽

Catheter Position ◽

Current Practices

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Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study

World Journal of Emergency Medicine ◽

10.5847/wjem.j.1920-8642.2017.01.004 ◽

2017 ◽

Vol 8 (1) ◽

pp. 25 ◽

Cited By ~ 8

Author(s):

Sean P. Wilson ◽

Samer Assaf ◽

Shadi Lahham ◽

Mohammad Subeh ◽

Alan Chiem ◽

...

Keyword(s):

Central Venous Catheter ◽

Prospective Study ◽

Point Of Care ◽

Venous Catheter ◽

Catheter Placement ◽

Point Of Care Ultrasound ◽

Central Venous ◽

Central Venous Catheter Placement ◽

A Prospective Study

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Implementering av PICC-line – en kvalitativ studie av anestesisykepleieres erfaringer

Nordisk tidsskrift for helseforskning ◽

10.7557/14.4470 ◽

2019 ◽

Vol 14 (2) ◽

Author(s):

Stine Thorvaldsen Smith ◽

Kristin Haraldstad

Keyword(s):

Central Venous Catheter ◽

Focus Groups ◽

Implementation Process ◽

Venous Catheter ◽

Nurse Anesthetists ◽

Successful Implementation ◽

Central Venous ◽

Hermeneutic Approach ◽

Picc Line ◽

Good Organization

PICC-line, a peripherally inserted central venous catheter has been implemented by several Norwegian hospitals in recent years. Nurse Anesthetists play an important role in this process, and have been given new tasks as a result of PICC-line implementation. This study aimed to describe Nurse Anesthetists’ experiences with implementation of PICC-line in hospital. A qualitative design, the data are based on three focus groups interviews with fifteen nurse anesthetists. The interviews were analyzed using a hermeneutic approach. Being a PICC-line nurse led to a feeling of competence, independence, motivation and meaningfulness. The implementation required good structure and organization, as well as enthusiasm. Collaboration and support influenced the implementation process. Good organization and enough available personnel, as well as good collaboration and support from the Anesthesiologists and the management are essential for a successful implementation.

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Implementation of ultrasound after central venous catheter insertion: A qualitative study in early adopters

The Journal of Vascular Access ◽

10.1177/11297298211053447 ◽

2021 ◽

pp. 112972982110534

Author(s):

Enyo A Ablordeppey ◽

Shannon M Keating ◽

Katherine M Brown ◽

Daniel L Theodoro ◽

Richard T Griffey ◽

...

Keyword(s):

Focus Group ◽

Central Venous Catheter ◽

Qualitative Analysis ◽

Focus Groups ◽

Venous Catheter ◽

Barriers And Facilitators ◽

Central Venous ◽

Focus Group Discussions ◽

Group Discussions ◽

Post Procedure

Background: The adoption rate of point of care ultrasound (POCUS) for the confirmation of central venous catheter (CVC) positioning and exclusion of post procedure pneumothorax is low despite advantages in workflow compared to traditional chest X-ray (CXR). To explore why, we convened focus groups to address barriers and facilitators of implementation for POCUS guided CVC confirmation and de-implementation of post-procedure CXR. Methods: We conducted focus groups with emergency medicine and critical care providers to discuss current practices in POCUS for CVC confirmation. The semi-structured focus group interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach (NVivo software), aiming to identify priority categories that describe the barriers and facilitators of POCUS guided CVC confirmation. Results: The coding dictionary of barriers and facilitators consisted of 21 codes from the focus group discussions. Our qualitative analysis revealed that 12 codes emerged spontaneously (inductively) within the focus group discussions and aligned directly to CFIR constructs. Common barriers included provider influences (e.g. knowledge and beliefs about POCUS for CVC confirmation), external network (e.g. societal guidelines, ancillary staff, and consultants), and inertia (habit or reflexive processes). Common facilitators included ultrasound protocol advantage and champions. Time and provider outcomes (cognitive offload, ownership, and independence) emerged as early barriers but late facilitators. Conclusion: Our qualitative analysis demonstrates real and perceived barriers against implementation of POCUS for CVC position confirmation and pneumothorax exclusion. Our findings discovered organizational and personal constructs that will inform development of multifaceted strategies toward implementation of POCUS after CVC insertion.

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