Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters

Ablordeppey, Enyo; Drewry, Anne M.; Theodoro, Daniel; Tian, Lin; Fuller, Brian M.; Griffey, Richard T.

doi:10.1097/shk.0000000000001218

Cited by 17 publications

(23 citation statements)

References 34 publications

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“…14,15,43 This demonstrates that brief, focused training in POCUS-guided CVC confirmation yields faster independent confirmation of CVC positioning even with POCUS nonexperts. In addition, given the high incidence of POCUS use during the insertion of the CVC, 22,44,45 the efficiency of postinsertion CVC confirmation would be augmented by streamlining the entire procedure during CVC insertion. This is an important consideration for implementation of POCUS-guided CVC CPEP into clinical practice.…”

Section: Discussionmentioning

confidence: 99%

“…One critical barrier is lack of training and a perception that ultrasound expertise is required to use this protocol. 22,23 To address this barrier and to evaluate the diagnostic accuracy of POCUS after brief training of nonexperts, we conducted a study comparing POCUS to CXR for CVC position confirmation and exclusion of pneumothorax in critically ill patients. We hypothesized that POCUS confirmation of CVC position and exclusion of pneumothorax could be implemented in a pragmatic fashion after brief, targeted POCUS education and training to POCUS nonexperts.…”

Section: Discussionmentioning

confidence: 99%

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

Ablordeppey

Drewry

Anderson

et al. 2020

AEM Education and Training

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Objective: Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts. Methods:We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.Results: Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Ablordeppey

Drewry

Anderson

et al. 2020

AEM Education and Training

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“…Although data support the use of POCUS as the rst approach for CVC PCEP, current practice patterns demonstrate that its use is nonexistent. [17,18] Radiography using CXR has been the standard method for con rming CVC placement for over 50 years. DRAUP would be a substantial change in the standard of care thus creating a critical translational gap for innovation implementation.…”

Section: Innovationmentioning

confidence: 99%

“…[9,10,[13][14][15][16] Even among providers with ultrasound experience, self-reported use of POCUS for CVC PCEP and de-adoption of CXR is low (1.5%), citing various barriers to this practice. [17,18] This demonstrates an important gap, necessitating advance in this space. De-implementation of routine chest radiographs after adoption of ultrasound guided insertion and con rmation of central venous catheter protocol (DRAUP) is designed to take advantage of an evidenced-based innovation (EBI) and de-implement low value CXR in the critical care environment using strategic interventions.…”

mentioning

confidence: 99%

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

Ablordeppey¹,

Powell²,

McKay³

et al. 2020

Preprint

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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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“…[13][14][15] However, the sole use of ultrasound in real practice is restricted by various factors, and CXR is still used in almost every case of CVC tip placement. 16 With a CXR, the position of the CVC tip can be confirmed relative to various anatomical landmarks in the chest. [17][18][19][20][21][22][23] Among these, the tip-to-carina (TC) distance has been previously shown to be a reliable indicator in several studies.…”

Section: Introductionmentioning

confidence: 99%

Chest radiography for simplified evaluation of central venous catheter tip positioning for safe and accurate haemodynamic monitoring: a retrospective observational study

et al. 2021

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ObjectivesThe tip-to-carina (TC) distance on a simple chest X-ray (CXR) has proven value in the determination of correct central venous catheter (CVC) positioning. However, previous studies have mostly focused on preventing the atrial insertion of the CVC tip, and not on appropriate positioning for accurate haemodynamic monitoring. We aimed to assess whether the TC distance could detect the passage of the CVC tip into the superior vena cava (SVC) and the right atrium (RA), and to accordingly suggest cut-off reference values for these two aspects.DesignRetrospective observational cohort study.SettingSingle urban tertiary level academic hospital.Participants479 patients who underwent CXR and chest CT scan after the insertion of a CVC with a 24-hour interval during the study period.InterventionThe TC distance was measured on CXR, and the position of the CVC tip was assessed on the chest CT images. The TC distance was described as a negative or positive number if the CVC tip was above or below the carina, respectively. Receiver-operating characteristics curve analyses were conducted to ascertain the TC distance to detect SVC entrance and RA insertion of CVC tip.ResultsThe TC distance could significantly detect both SVC entrance and RA insertion (p<0.001 for both; area under curve 0.987 and 0.965, respectively), with a reference range of −6.69 to 15.61 mm.ConclusionThe TC distance in CXR is a simple and precise method to confirm not only the safe placement of the CVC tip but also its optimal positioning for accurate haemodynamic monitoring.

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Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters

Cited by 17 publications

References 34 publications

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

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

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

Chest radiography for simplified evaluation of central venous catheter tip positioning for safe and accurate haemodynamic monitoring: a retrospective observational study

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