Improving Protocol Adherence in Central Line Placements

BACKGROUND: 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.