Preventing Complications of Central Venous Catheterization

McGee, David C.; Gould, Michael K.

doi:10.1056/nejmra011883

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“…4-8 Pneumothorax rates for internal jugular (IJ) CVCs have been reported to range from 0% to 0.2% and for subclavian (SC) CVCs from 1.5% to 3.1%. 4,5 The arterial puncture rate for IJ CVCs ranges from 5.0% to 9.4% and for SC CVCs from 3.1% to 4.9%. 4,5 Proper use of ultrasound to assist with IJ CVC insertion has been shown to decrease these mechanical complications.…”

Section: Designmentioning

confidence: 99%

“…4,5 However, studies of ultrasound use with SC CVC insertion have mixed results. 4 Simulation-based training has been used in medical education to increase knowledge, provide opportunities for deliberate and safe practice, and shape the development of …”

mentioning

confidence: 99%

“…The arterial puncture rate of 7% among simulator-trained residents was higher than expected, although it remains within published ranges. 4,5 Also, a low total number of CVCs were evaluated during the study. This is likely due to strict exclusion criteria employed in order to study the impact of simulation training.…”

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Use of simulation‐based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit

McGaghie

Cohen

Balachandran

et al. 2009

Journal of Hospital Medicine

351

272

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Disclosure: The authors have no financial or other potential conflicts of interest.BACKGROUND: Central venous catheter (CVC) insertions are performed frequently by internal medicine residents.Complications, including arterial puncture and pneumothorax, decrease when operators use fewer needle passes to insert the CVC. In this study, we evaluated the effect of simulation-based mastery learning on CVC insertion skill. DESIGN:This was a cohort study of internal jugular (IJ) and subclavian (SC) CVC insertions by 41 internal medicine residents rotating through the medical intensive care unit (MICU) over a five-month period. Thirteen traditionallytrained residents were surveyed about the number of needle passes, complications, and procedural self-confidence on CVCs inserted in the MICU. Concurrently, 28 residents completed simulation-based training in IJ and SC CVC insertions. Simulator-trained residents were expected to perform CVC insertions to mastery standards on a central line simulator. Simulator-trained residents then rotated through the MICU and were surveyed regarding CVC placement. The impact of simulation training was assessed by comparing group survey results. Central venous catheter (CVC) insertions are commonly performed at the bedside in medical intensive care unit (MICU) settings. Internal medicine residents are required to demonstrate knowledge regarding CVC indications, complications, and sterile technique, 1 and often perform the procedure during training. Education in CVC insertion is needed because many internal medicine residents are uncomfortable performing this procedure. 2 CVC insertion also carries the risk of potentially life-threatening complications including infection, pneumothorax, arterial puncture, deep vein thrombosis, and bleeding. Education and training may also contribute to improved patient care because increased physician experience with CVC insertion reduces complication risk. 3,4 Similarly, a higher number of needle passes or attempts during CVC insertion correlates with mechanical complications such as pneumothorax or arterial punctures. 4-8 Pneumothorax rates for internal jugular (IJ) CVCs have been reported to range from 0% to 0.2% and for subclavian (SC) CVCs from 1.5% to 3.1%. 4,5 The arterial puncture rate for IJ CVCs ranges from 5.0% to 9.4% and for SC CVCs from 3.1% to 4.9%. 4,5 Proper use of ultrasound to assist with IJ CVC insertion has been shown to decrease these mechanical complications. 4,5 However, studies of ultrasound use with SC CVC insertion have mixed results. 4 Simulation-based training has been used in medical education to increase knowledge, provide opportunities for deliberate and safe practice, and shape the development of RESULTS: Journal of Hospital Medicine Vol 4 No 7 September 2009 397clinical skills. 9,10 We previously used simulation-based mastery learning to improve the thoracentesis and advanced cardiac life support (ACLS) skills of internal medicine residents. 11,12 Although a few small studies have linked simulation-based interventions to imp...

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Use of simulation‐based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit

McGaghie

Cohen

Balachandran

et al. 2009

Journal of Hospital Medicine

351

272

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“…Although in our study complications were infrequent, suggesting that a change in venous insertion site is unlikely to dramatically improve patient safety, we believe that residents should become skilled at inserting catheters in internal jugular or subclavian veins, the currently recommended optimal venous insertion. 8 There is evidence that single educational interventions are unlikely to result in substantial, sustained behavioral change, especially passive educational programs. 11 However, a previous study documented a change in provider behavior and possibly a reduction in bloodstream infections after a single hands-on training session.…”

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confidence: 99%

“…7 In our hospital, most catheters are placed in the femoral vein. Because femoral venous placement likely increases a patient's risk of thrombosis, hematoma, and bloodstream infection, 8 we developed a program to change residents' choice of venous insertion site and improve their infection-control practices during their general medicine ward rotation. The program provided simulated hands-on experience in a simulation laboratory.…”

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Firm‐based trial to improve central venous catheter insertion practices

Miranda

Trick

Evans

et al. 2007

Journal of Hospital Medicine

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BACKGROUNDCentral venous catheters placed in femoral veins increase the risk of complications. At our institution, residents place most catheters in the femoral vein.OBJECTIVEDetermine whether a hands‐on educational session reduced femoral venous catheterization and improved residents' confidence and adherence to recommendations for infection control.DESIGNFirm‐based clinical trial between November 2004 and March 2005.SETTINGGeneral medical wards of Cook County (Stroger) Hospital (Chicago, IL), a public teaching hospital.PARTICIPANTSInternal medicine residents (n = 150).INTERVENTIONBefore their 4‐week rotation, intervention‐firm residents received a lecture and practiced placing catheters in mannequins; control‐firm residents received the usual training.MEASUREMENTSVenous insertion site, adherence to recommendations for infection control, knowledge and confidence about catheter insertion, and catheter‐associated complicationsRESULTSResidents inserted 54 catheters, or 0.24 insertions per resident per 4‐week rotation. There was a nonsignificant decrease in femoral insertions for nondialysis catheters in the intervention group compared to the control group (44% vs. 58%), difference: −14% (95% CI, −52% to 24%). The intervention significantly increased residents' knowledge of complications related to femoral vein catheterization and temporarily increased their confidence about placing internal jugular or subclavian venous catheters. Intervention‐group residents were more likely to use masks during catheterization (risk ratio, 2.2; 95% CI, 1.3‐2.7), but other practices were similar.CONCLUSIONSOur intervention improved residents' knowledge of complications and use of masks during catheter insertion; however, it did not significantly change venous insertion sites. Catheter insertions on our general medicine wards are infrequent, and the skills acquired during the skills‐building session may have deteriorated given the few clinical opportunities for reinforcement. Journal of Hospital Medicine 2007;2:135–142. © 2007 Society of Hospital Medicine.

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