Emergency and critical care providers’ perception about the use of bedside ultrasound for confirmation of above-diaphragm central venous catheter placement

Abstract

Introduction: Chest radiography (CXR) is commonly used to confirm the proper placement of above-diaphragm central venous catheters (CVCs) and to detect associated complications. Recent studies have shown that pointof-care ultrasound (POCUS) has better sensitivity and is faster than CXR for these purposes. We were interested in documenting how often emergency medicine and critical care practitioners perform POCUS to confirm proper CVC positioning as well as their confidence in performing it. Methods: We surveyed members of our state's chapters of the College of Emergency Physicians and the Society of Critical Care Medicine between April and December 2018. Our primary outcome was the percentage of providers who would agree to perform only POCUS, forgoing CXR, for confirmation of CVC position. We performed multivariable logistic regressions to measure associations between demographic, clinical information, and outcomes. Results: One hundred thirty-six providers participated (a 25% participation rate). Their specialties were as follows: emergency medicine, 75%; critical care, 13%; and emergency medicine/critical care, 11%. Thirty-one percent would use POCUS only for CVC confirmation, while 42% were confident in performing POCUS for this purpose. Multivariable logistic regressions showed that performing more non-procedural ultrasound examinations was associated with a higher likelihood of agreeing to perform POCUS only (OR, 2.9; 95% CI: 1.3-6.3). Forty-six percent of relevant comments suggested more training to increase the use of POCUS. Conclusion: Participants in this study did not frequently use POCUS for CVC confirmation. Designers of training curricula should consider including more instruction in the use of POCUS to confirm proper CVC placement and to detect complications.

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

“…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.…”

“…To our knowledge, POCUS-guided CVC confirmation is not routinely taught to trainees. 22,23 Our study recognizes this important gap in clinical practice and aims to pragmatically address this barrier by providing evidence if a brief and targeted training to a large group of POCUS nonexperts in a busy academic training programs is sufficient to accomplish diagnostic accuracy, efficiency, and feasibility for POCUS detection of catheter malposition and pneumothorax.…”

The Use of POCUS to Manage ICU Patients With COVID‐19

“…59 Adoption of this recommendation remains low, as only 24% of emergency medicine and critical care providers use POCUS to confirm a CVC and exclude a pneumothorax based on a recent survey. 60 In the COVID-19 pandemic this represents a lost opportunity to not only optimize patient care but reduce transmission risk by eliminating radiographs.…”

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

“…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.…”

“…[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.…”