Evidence-based consensus on the insertion of central venous access devices: definition of minimal requirements for training

Focused Simulation Training: Emergency Department Nurses’ Confidence and Comfort Level in Performing Ultrasound-Guided Vascular Access

Study objectives

The objective of this study is to assess Emergency Department (ED) nurses’ confidence, comfort level, and competency in performing ultrasound-guided vascular access after a focused ultrasound simulation training session.

Methods

A cross-sectional study at an academic medical center. A simulation-based ultrasound training module was used to train ED nurses in ultrasound-guided intravenous (IV) access. The training module consisted of didactics followed by hands-on practice on human models and Blue Phantom ultrasound training block model. All subjects completed a questionnaire after completing the training module.

Results

A total of 40 nurses were enrolled. All subjects successfully demonstrated competency during the training session by identifying upper extremity sonographic vascular anatomy on a human model and performing real-time ultrasound-guided IV access on Blue Phantom ultrasound training block model. On a scale of 1-10, the average confidence level in performing the ultrasound-guided vascular access was 6.9 [95% confidence interval (95% CI) 6.3-7.46], with 98% (95% CI, 92-102%) reporting no difficulty in recognizing upper limb vascular anatomy on ultrasound. Ninety-two percent (95% CI, 84-100%) agreed that focused training in ultrasound-guided IV access was adequate to learn the procedure.

Conclusions

After a focused simulation training session, ED nurses had a high level of comfort using ultrasound for vascular access. Despite having a moderate degree of confidence, ED nurses were accurate in identifying vascular anatomy and performing ultrasound-guided vascular access.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Evaluation of a Pilot Educational Program on Safe and Effective Insertion and Management of Peripheral Intravenous Catheters

Peripheral intravenous catheter (PIVC) insertion and subsequent care have been highlighted as areas for improvement in the management of intravascular devices; however, only the fundamentals of PIVC care are routinely taught to registered nurses in Australia. In 2013, a vascular access-focused elective postgraduate course, Peripheral Intravenous Access and Care (8035NRS) was commenced for students enrolled in any of the Griffith University master's degree programs. It was developed with the intent to translate research knowledge into practice by providing access to the latest research findings and current best practices in peripheral intravenous access. Topics covered preinsertion, insertion, and postinsertion care and were developed for the online environment, which is known to be conducive to individual student learning styles. Learning activities included viewing short videos delivered by local and international clinical researchers. This course is the first known university-provided, postgraduate academic course on this subject in Australia, and possibly 1 of the few available internationally. The course succeeded in its aim of increasing knowledge and skills about safe, evidence-based PIVC insertion and care to registered nurses. Its development and implementation at the postgraduate level may be regarded as a strategy to provide a greater understanding regarding scope and relevance for nursing practice and for informed decision making on optimum integration at the undergraduate level. This ultimately will increase positive patient outcomes and the patient experience of vascular access.

Ultrasound-guided subclavian venipuncture is more rapidly learned than the anatomic landmark technique in simulation training

PURPOSE

Both ultrasound-guided subclavian venipuncture (US-SV) and landmark-guided subclavian venipuncture (LM-SV) are important in critical care, because the clinical utility of ultrasound guidance is still debated. Education of residents and medical students should include both techniques. The aim of this study is to compare learning these two techniques in a simulation environment.

METHODS

This study was approved by the research ethics review committee. Trainees included residents and medical students who were instructed using the "Videos in Clinical Medicine" for LM-SV, or a dedicated slide series for US-SV, using the long-axis in-plane with needle-guide technique. After the lecture, trainees attempted to perform venipuncture in a simulator. All participants performed both techniques. The procedure time from initial skin puncture to detecting back-flow of fluid from the simulated vein was measured. A procedure time over 3 min, arterial puncture, or pneumothorax was counted as a failure. The end-point for each trainee was three successive successful venipunctures without a failure. A trainee who reached the end-point was considered as having acquired adequate skill. Statistical analysis of the procedure time comparing the techniques was done using the Mann-Whitney U test.

RESULTS

Twenty trainees participated in this training. Adequate skill to perform US-SV was achieved within three tries, but up to nine attempts were needed for LM-SV. One arterial puncture occurred during LM-SV. No pneumothoraxes occurred during the simulation training.

CONCLUSIONS

US-SV was learned more quickly than LM-SV in a simulation model.

The impacts of observing flawed and flawless demonstrations on clinical skill learning

OBJECTIVES

Clinical skills expertise can be advanced through accessible and cost-effective video-based observational practice activities. Previous findings suggest that the observation of performances of skills that include flaws can be beneficial to trainees. Observing the scope of variability within a skilled movement allows learners to develop strategies to manage the potential for and consequences associated with errors. This study tests this observational learning approach on the development of the skills of central line insertion (CLI).

METHODS

Medical trainees with no CLI experience (n = 39) were randomised to three observational practice groups: a group which viewed and assessed videos of an expert performing a CLI without any errors (F); a group which viewed and assessed videos that contained a mix of flawless and errorful performances (E), and a group which viewed the same videos as the E group but were also given information concerning the correctness of their assessments (FA). All participants interacted with their observational videos each day for 4 days. Following this period, participants returned to the laboratory and performed a simulation-based insertion, which was assessed using a standard checklist and a global rating scale for the skill. These ratings served as the dependent measures for analysis.

RESULTS

The checklist analysis revealed no differences between observational learning groups (grand mean ± standard error: [20.3 ± 0.7]/25). However, the global rating analysis revealed a main effect of group (d.f.2,36 = 4.51, p = 0.018), which describes better CLI performance in the FA group, compared with the F and E groups.

CONCLUSIONS

Observational practice that includes errors improves the global performance aspects of clinical skill learning as long as learners are given confirmation that what they are observing is errorful. These findings provide a refined perspective on the optimal organisation of skill education programmes that combine physical and observational practice activities.

Current use of ultrasound for central vascular access in children and infants in the Nordic countries--a cross-sectional study

PURPOSE

The use of ultrasound (US) guidance for central vascular access in children has been advocated as a safer approach compared to traditional landmark techniques. We therefore collected data on the current use of US for central vascular access in children and infants in the Nordic countries.

METHODS

A cross-sectional survey using an online questionnaire was distributed to one anaesthesiologist at every hospital in the Nordic countries; a total of 177 anaesthesiologists were contacted from July till August 2012.

RESULTS

The use of US for placing central venous catheters (CVCs) seems widespread across the Nordic countries. Close to 80% of respondents were using it "almost always" or "frequently" across all paediatric age groups for internal jugular vein cannulation. US was least frequently used when catheterizing the subclavian vein. The two most common reasons given when not using US were lack of training followed by lack of equipment. We found no difference in the use of US between high-volume centres and low-volume centres. (High-volume centres placed paediatric CVCs at least weekly.).

CONCLUSIONS

US was commonly used for cannulation of the internal jugular vein but infrequently for the subclavian vein. A lack of training seems to be a barrier for further increasing the use of US. Establishing standardized training programmes based on current evidence should alleviate this.

Simulation-based paediatric intensive care unit central venous line maintenance bundle training

OBJECTIVE

Research has demonstrated that additional reduction in paediatric catheter associated blood stream infection (CA-BSI) rates can be achieved through improving compliance with maintenance bundle care for central venous lines. Our objective was to improve maintenance bundle compliance rates and nursing competency surrounding central venous line (CVL) care in our paediatric intensive care unit (PICU).

METHODS

A multidisciplinary team developed a bedside simulation-based training programme to improve compliance with standard PICU CVL maintenance bundle. We then performed a randomised comparison study comparing a standard CVL bundle training process for bedside PICU nurses in a control group (CG) to an intervention group (IG) receiving bedside training to simulate a CVL dressing change and maintenance bundle followed by intermittent training refreshers. Groups were assessed for compliance with prescribed components of the CVL bundle maintenance (CVL score).

RESULTS

At baseline the CG and IG had similar mean CVL scores (p=0.725). At twelve months mean CVL bundle compliance score in the IG was significantly higher than in the CG (p<0.0001). The largest CVL score increase for IG occurred between zero and three months. Coincidentally, CA-BSI rates in the Egleston PICU significantly decreased from 1.9±2.2 BSIsper 1000/CVL days, prior to the study, to 0.6±1.6 BSIsper 1000/CVL days following implementation of the intervention (p=0.034).

CONCLUSIONS

Bedside simulation based training in CVL dressing change is associated with improved compliance with CVL maintenance bundle practice. Enhanced CVL maintenance bundle practice could contribute to reduction in CA-BSI rates.

The three-step method for ultrasound-guided pediatric internal jugular venous catheterization: a clinical trial

Ultrasound guidance may be a valuable adjunct for pediatric internal jugular vein catheterization. We previously reported a long-axis in plane technique, called the "three-step method", resulting in high success and a low complication rate by novice operators in adult patients. This is the first report of ultrasound-guided internal jugular vein catheterization (US-IJV) using the three-step method in pediatric patients. Fourteen junior residents underwent simulation training, and then participated in a clinical trial. They performed US-IJV in 14 pediatric patients with congenital heart disease before undergoing cardiac surgery under supervision of an experienced clinician. The overall success rate was 93 %, and all catheterizations were performed within two venipunctures. There were no complications associated with the procedure. The three-step method may facilitate pediatric US-IJV even by a novice operator during their first experience.

Training the next generation's nephrology workforce

The subspecialty of nephrology faces several critical challenges, including declining interest among medical students and internal medicine residents and worrisome declines in the number of applicants for nephrology fellowships. There is an urgent need to more clearly define the subspecialty and its scope of practice, reinvigorate meaningful research training and activities among trainees, and ensure that fellows who complete training and enter the practice of nephrology are experts in the broad scope of nephrology. This need requires a critical look at fellowship training programs and training requirements. A new workforce analysis is also needed that is not focused on primarily meeting estimated future clinical needs but rather, ensuring that there is alignment of supply and demand for nephrology trainees, which will ensure that those entering nephrology fellowships are highly qualified and capable of becoming outstanding nephrologists and that there are desirable employment opportunities for them when they complete their training.

Are peripherally inserted central catheters associated with increased risk of adverse events in status 1B patients awaiting transplantation on continuous intravenous milrinone?

BACKGROUND

Peripherally inserted central catheters (PICCs) are used to deliver continuous intravenous (IV) milrinone in stage D heart failure (HF) patients awaiting heart transplantation (HT).

METHODS

We retrospectively analyzed PICC adverse events (AEs) and associated cost in 129 status 1B patients from 2005 to 2012. End points were HT, left ventricular assist device (LVAD), and death. Regression analysis was used to identify AE risk factors.

RESULTS

Fifty-three PICC AEs occurred in 35 patients (27%), consisting of 48 infections, 4 thromboses, and 1 bleeding event. Median duration of PICC support was 63 (interquartile range [IQR] 34-131) days, and median time to first PICC infection was 44 (IQR 14-76) days. Among PICC infections, 9% required defibrillator removal and 30% were inactivated on the HT list for a mean of 23 ± 17 days. Rate of HT, LVAD, or death was similar between groups (P > .05). Regression analysis found that a double lumen PICC was associated with a shorter time to first PICC infection (hazard ratio 7.59, 95% CI 1.97-29.23; P = .003). Median cost per PICC infection was $10,704 (IQR $7,401-$26,083).

CONCLUSIONS

PICC infections were the most frequent AEs. PICCs with >1 lumen were associated with increased risk of infection. PICC AEs accounted for increased intensive care unit admissions, HT list inactivations, and overall cost.

Ultrasound guided vascular access in pediatric cardiac critical care

INTRODUCTION

Safely obtaining vascular access in the pediatric population is challenging. This report highlights our real-world experience in developing a safer approach to obtaining vascular access using ultrasound guidance in children and infants with congenital heart disease.

METHODS

As part of a quality initiative, we prospectively monitored outcomes of all vascular access attempts guided by ultrasound from January 2010 to September 2010. Variables monitored included age, weight, the time from first needle puncture to wire insertion, site of insertion, number of attempts, type of line, and complications.

RESULTS

There were 77 attempts (15 arterial and 62 venous) to obtain vascular access in 43 patients. The mean age was 15 months (6 days-11 years; median 2.5 months). The mean weight was 7.2 kg (2-46 kg, median 3.8). Success rates were 93% and 95% for arterial and venous cannulation, respectively. Mean time from first needle puncture to wire insertion was 3.9 min (0.5-15 min, median 2 min). Fifty-five (75%) central line cannulations were successful from the first puncture; 17(23%) were successful from the second puncture; and one case (2%) required three punctures. Thirty patients (45%) weighed less than 3.5 kg. This lower body weight did not affect success rate, which was unexpectedly high (96.6%). There were no associated complications.

CONCLUSION

Ultrasound guided vascular cannulation in critically ill pediatric patients is safe, effective and efficient. This approach had a high success rate, and was associated with zero complications in our setting.

Vein Measurement by Peripherally Inserted Central Catheter Nurses Using Ultrasound: A Reliability Study

Background: Peripherally inserted central catheters (PICCs) are increasingly inserted by trained registered nurses, necessitating the development of specialized skills such as the use of ultrasound. The selection of an adequately sized vein is an important factor in reducing adverse events such as deep vein thrombosis. However, PICC nurses may receive minimal training in the use of ultrasound for vein measurement.

Objective: We aimed to demonstrate the reliability of a vein measurement protocol using ultrasound by a PICC nurse trained in sonography.

Methods: The diameter of the basilic, brachial, and cephalic veins in the left arms of healthy participants (n =12) were measured using ultrasound by a PICC nurse and a sonographer. A PICC nurse performed the measurement twice and the sonographer once; the PICC nurse's results were compared for intra-rater reliability and compared with the sonographer for inter-rater reliability. The results were analyzed using intraclass correlation coefficients (ICCs).

Results: Inter-rater reliability between the PICC nurse and the sonographer was adequate, the ICC for the brachial vein was 0.60 (95% confidence interval [CI], 0.06–0.87), basilic vein ICC was 0.87 (95% CI, 0.58–0.96) and cephalic vein ICC was 0.77 (95% CI, 0.39–0.93). Intra-rater reliability of the PICC nurse was higher; the ICC for the brachial vein was 0.80 (95% CI, 0.44–0.94), basilic vein ICC was 0.92 (95% CI, 0.67–0.98), and cephalic vein ICC was 0.78 (95% CI, 0.40–0.93).

Conclusions: Using a suitable protocol, a PICC nurse was able to measure vein diameter reliably when compared with a sonographer and consistently replicate these results.

Right line, right patient, right time: every choice matters

The field of vascular access has developed significantly over recent decades. It has been adapted to provide a range of techniques for a range of patients much faster than a full appreciation of the risks involved has developed. Improved governance of vascular access procedures in the UK is needed. This is driven by a deeper understanding of risks such as infectious and thrombotic complications, repeated failures of peripheral intravenous (IV) access leading to poor patient experience and treatment inadequacy, and the increasing emphasis on avoiding healthcare-associated infections. The Vessel Health and Preservation (VHP) protocol, which is used to standardise vascular access practice in the US is being evaluated for adoption in the UK. A comprehensive and inclusive approach should be taken to the vascular access needs of all patients.

Assessing the Quality of Central Venous Catheter and Peripherally Inserted Central Catheter Videos on the YouTube Video-Sharing Web site

Background: Video sharing networks such as YouTube have revolutionized communication. Whilst access is freely available uploaded videos can contain non peer-reviewed information. This has consequences for the scientific and health care community, when the challenge in teaching is to present clinical procedures that follow empirical methods.

Objective: To review 50 central venous catheter and peripherally inserted central catheter videos posted on YouTube. The aim was to appraise these videos using current evidenced-based guidelines.

Methods: We searched YouTube using the key words central venous cannulation and peripherally inserted central catheter insertion on September 21, 2012. We consecutively reviewed 50 videos for both procedures.

Results: There was poor adherence to evidence-based guidelines in the critiqued videos. There was a difference in adherence with the use of appropriate skin antisepsis in the 2 groups (18% for central venous catheters vs 52% for peripherally inserted central catheters; p = 0.009). And a large proportion in both groups compromised aseptic technique (37% for central venous catheters vs 38% for peripherally inserted central catheter; p = 0.940). The use of ultrasound guidance during procedures was also different between the 2 groups (33% for central venous catheters vs 85% for peripherally inserted central catheters; p = 0.017).

Conclusions: This critique of instructional videos related to the insertion of central venous catheters and peripherally inserted central catheters uploaded to YouTube has highlighted poor adherence to current evidence-based guidelines. This lack of adherence to empirical guidelines can pose risks to clinical learning and ultimately to patient safety.