Browsing by Subject "Catheterization, Central Venous"
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Item Improving Protocol Adherence in Central Line Placements(2022-05-01T05:00:00.000Z) Roy, Mathews Francis; Goff, Kristina L.; Yager, Ashley; Reed, W. GaryBACKGROUND: The placement of central lines is a very common exercise in medicine. Central lines are required for everything from acute trauma scenarios to long term cancer treatments. However, this ubiquitous procedure has several morbid complications that are not uncommon. Possible complications include infection, catheter misplacement, arterial puncture, hematoma, pneumothorax, and death[1]. Not only are the complications severe they are also quite prevalent with a complication rate of 15 to 25 percent[2]. LOCAL PROBLEM: Due to a concern for the rates of central line infections across campuses at the University of Texas Southwestern Medical Center (UTSW) there was a project underway to create a standardized central line placement protocol for all departments in the system. This protocol was taught to all incoming residents on a simulation session day. However, because a significant period of time can pass between central line training and the clinical practice of placing central lines, the rate of resident retention and adherence to the standardized procedure for central line placement is unknown. This report describes the results of a QI experiment meant to reduce the rate of catheter associated blood stream infections and ensure better resident protocol adherence at UTSW medical center using checklists and visual aids to ensure implementation of the standardized protocols. METHODS: The study was split into three phases. The first phase examined the baseline knowledge of UTSW residents regarding the placement of central lines and found the nursing position regarding possible interventions. The residents were interviewed regarding the standardized UTSW protocol and asked to detail the steps of placing a central line. The results were used to analyses areas of weakness in protocol adherence. Based on the results of the interviews, a checklist and visual aid were created highlighting key steps to ensure the adherence to the protocol. In phase two, to evaluate the feasibility of incorporating a checklist and CVA into the original CVC insertion methodology, a simulated pilot was conducted, and a survey was completed by the participants to determine how staff perceived the use of these new tools. In phase three after analyzing the ability to integrate the checklist and visual aid in a simulated setting, the utility of using a checklist to improve CVC insertions was tested by conducting a pilot study on real patients. During the pilot, CVCs placed in the ICU were observed by a medical student with the bedside nurse's participation and real time completion of the checklist RESULTS: Phase 1: It was found that there were significant variations in the average adherence between departments and training years. On average, post graduate year (PGY)3s did better than PGY2s. Furthermore, it was found that 50% of missed steps were caused by only 8 out 36 questions and 75% of mistakes were caused by just 15 out of 36 questions. Phase 2: Simulated pilot Survey results showed that all participants felt that their team successfully followed the standardized placement method. The participants also said that the implemented huddle helped to create teamwork and organization, and that it could easily be incorporated into the normal workflow. Phase 3: In-practice pilot All trial participants were asked for feedback regarding the perceived benefit of the process. Results were very positive with most participants saying that they thought that the new workflow was helpful and easy to implement. Analysis of the completed checklists show that participants were able to complete the forms without issue ensuring that complete adherence to the standardized protocol was possible. CONCLUSIONS: By interviewing residents to understand areas of difficulties and going through a multistep approach to ensure safety and efficacy of interventions, this project provides insight into the possible gaps in resident procedure adherences and retention of the UTSW protocol. It then also provides an intervention that strengthen the memory of the preforming physician and a layer of oversight to ensure that even if a mistake is made it is quickly corrected. The general concepts of simulation trials prior to clinical application and utilization of a checklist and cognitive visual aid can be applied not only to central lines at UTSW, but to many different procedures across multiple hospital systems.Item Long Term Central Venous Access in a Pediatric Leukemia Population(2015-01-26) Fu, Aurelia; Hodgman, Erica; Renkes, Rachel; Slone, Tamra; Alder, AdamBACKGROUND: Central venous access devices (CVADs) are used during the treatment of malignancies to facilitate chemotherapy administration and to reduce the pain and trauma of frequent blood sampling. Despite the importance of venous access, there is little recent data on complication rates associated with CVADs among pediatric patients. Our aim was to retrospectively analyze the complication rates among patients with acute leukemia at a single pediatric tertiary referral center. METHODS: After IRB approval, we reviewed the medical records of all patients with a diagnosis of acute lymphoblastic leukemia or acute myeloid leukemia admitted to our institution from May 2009-July 2014. Patient data, including demographics, CVAD type (subcutaneous port or tunneled catheter), peri-operative complications (<24 hours of surgery), long-term complications (>24 hours after surgery), and overall patient outcomes were collected. Chi square, t-tests and backward stepwise multivariate-regressions were used (significance p<0.05). RESULTS: There were 292 CVADs placed in 198 patients. The peri-operative complication rate was 4.8% (14 out of 292). Out of 292 CVADs, 23 did not have any long-term complications. Long-term complications included 93 line-associated infections (blood stream and/or port site infections), 6 episodes of deep vein thrombosis (DVT), and 136 instances of line malfunction without an identifiable cause. Seventy-five CVAD's were prematurely removed: 31 due to infection and 44 to malfunction. Univariate analysis identified age as a risk factor for a hematoma (p=0.02), and weight status as a risk factor for blood stream infection (p=0.02), DVT (p=0.009), line malfunction (p=0.02), and premature removal (p=0.02). The number of days from diagnosis to CVAD placement (p=0.008) and location of the subcutaneous port reservoir (p=0.01) were identified as predictors of early CVAD removal by multivariate analysis. There were no significant differences in long term complications between ports or tunneled catheters. CONCLUSION: Our rate of peri-operative complications compares to the 1.3-14% range reported in previous studies. Long term complications are high and require additional treatment, catheter replacement, or premature removal. This is costly in health, time, and money for both the patient and our institution, and should be addressed to improve patient care. Our retrospective study is the largest recent evaluation of CVAD complications within a single institution and also represents the largest Hispanic pediatric leukemia population reported upon to date.Item Standardization of Internal Jugular Central Venous Catheter Insertion Between Multiple Specialties with Simulation(2018-03-29) Weia, Benjamin Chun-Bang; Reed, W. Gary; Sulistio, Melanie; Phelps, EleanorBACKGROUND: Insertion of central venous catheters is a medical procedure with the risk of adverse outcomes. Between the different specialties at the University of Texas Southwestern Medical Center (UT Southwestern), there is a wide variation in the training and performance of the procedure. At other medical institutions, standardization of central venous catheter insertion decreased the frequency of adverse outcomes including failure, infection, pneumothorax, and arterial puncture. SPECIFIC AIM: Increase compliance with a standardized method for central venous catheter insertion among resident physicians in six departments at UT Southwestern to 95% as measured by a checklist by July 2019. METHODS: Consensus was achieved on a standardized method between six departments by a modified Delphi method. A training curriculum was created for the standardized method by following the Define-Measure-Analyze-Design-Validate (DMADV) framework. In designing the curriculum, strategies were utilized from implementation science, mastery-based learning, and simulation education. During the design phase, the curriculum was improved through two Plan-Do-Study-Act cycles with two pilot training sessions. RESULTS: Created a checklist for measuring compliance to the standardized method and a written exam for measuring knowledge required for the method. Designed multiple manuals and a video for learners and educators to standardize the training. CONCLUSION: A standardized method for inserting central venous catheters has been developed with consensus between multiple departments in a large academic institution. To introduce compliance with the method, a simulation-based training curriculum has been implemented. These achievements allow for the following phase of training resident physicians at UT Southwestern and measuring for an increase in compliance to the standardized method for central venous catheter insertion.Item UT Southwestern Standardization of IJ CVC Insertion Across Multiple Specialties(2018-03-29) Kuo, Eric Jia-Young; Reed, W. Gary; Sulistio, Melanie; Phelps, EleanorBACKGROUND: Standardization of procedures decreases patient complications and improves patient care. University of Texas Southwestern(UTSW) Medical Center is a large academic institution that fosters/trains physicians from all over the country and world. The diversity of physician background in specialties and clinical interests leads to a large variation for the teaching and insertion of internal jugular(IJ) central venous catheters (CVC). In order to improve clinical training of residents and decrease patient harm, the standardization of IJ CVC insertion was undertaken at UTSW. OBJECTIVE: Standardize IJ CVC Insertion Across All Specialties at UTSW METHODS: Stakeholders were identified at the project's inception for proper sponsorship and support. Consensus across multiple specialties was achieved using a modified Delphi method. Process Map was generated using previously identified standards of practice1,2,3 for CVC insertion and modified for implementation according to resources specific to UTSW hospital system. UTSW Checklist was created based on expert consensus and the UTSW process map that included elements from work done by other academic institutions4-12. Education resources were created tailored to the UTSW process map in order to create a simulation training for future physicians and residents at UTSW. Training Video and exams were created to measure learner's competency/retention of UTSW IJ CVC insertion. RESULTS: Consensus for one method of IJ CVC insertion across multiple specialties was achieved. Checklist, educator manual, learner manual, and video were created specific to UTSW CVC insertion method. Simulation training of UTSW Physicians was begun on March 19, 2018. CONCLUSION: Creation of the UTSW IJ CVC insertion method and a simulation curriculum to teach residents/physicians was successful. Future work could be collected on hospital complications rates associated with CVC insertion and comparing the complications of 2018-2019 year to prior 2017-2018 year. Residents can be followed at 6 months intervals out of simulation training to determine retention and mastery of skill.