JMIR Publications

ABSTRACT

Background:

Central venous catheterization (CVC) is a very common procedure performed across medical and surgical wards as well as intensive care units. It provides relatively extended vascular access for critically ill patients, in order to the administer intricate life-saving medications, blood products and parenteral nutrition. Major vascular catheterization provides a risk of easy accessibility and dissemination of catheter related infections as well as venous thromboembolism. Therefore, its crucial to ensure following standardized practices while insertion and management of CVC in order to minimize the infection risks and procedural complications. The aim of these central line insertion guidelines is to address the primary concerns related to predisposition of Central line associated blood stream infections (CLABSI). These guidelines are evidence based and gathered from pre-existing data associated with CVC insertion. The most common used sites for central venous catheterization are internal jugular and subclavian veins as compared to femoral veins. Catheterization of these vessels enables healthcare professionals to monitor hemodynamic parameters while ensuring lower risks of CLABSI and thromboembolism. Femoral vein is less preferred due to advantage of invasive hemodynamic monitoring and low risk of local infection and thromboembolic phenomena. CVC can be inserted using Landmark guided technique and ultrasound guided techniques. Following informed consent, the aseptic technique for CVC insertion includes performing appropriate hand hygiene and ensuring personal protective measures, establishing and maintaining sterile field, preparation of the site using chlorhexidine, and draping the patient in a sterile manner from head to toe. Additionally, the catheter is prepared by pre-flushing and clamping all unused lumens, and the patient is placed in the Trendelenburg position. Throughout the procedure, maintaining a firm grasp on the guide wire is essential, which is subsequently removed post-procedure. It is followed by flushing and aspirating blood from all lumens, applying sterile caps, and confirming venous placement. Procedure is ended with cleaning the catheter site with chlorhexidine, and application of a sterile dressing. Hence, formal training and knowledge of standardized practices of CVC insertion is essential for health care professionals in order to prevent CLABSI. Our audit assesses the current practices of doctors working at a tertiary care hospital to analyze their background knowledge of standard practices to prevent CLABSI during insertion of CVC.

Objective:

This study was aimed to audit and re-audit residents’ practices of central venous line insertion in medical and nephrology units of A Tertiary Care Hospital of Rawalpindi, Pakistan and to assess the adherence of residents to checklist and practice guidelines of CVC insertion implemented by John Hopkins Hospital and American Society of Anesthesiologists.

Methods:

This audit was conducted as a cross sectional direct observational study and two-phase quality improvement project in the Medical and Nephrology Units of a Tertiary Care Hospital of Rawalpindi from December 2023 to February 2024. After taking informed consent from patients and residents, CVC insertion in 34 patients by 34 individual residents was observed. Observers were given a purposely designed observational tool made from John Hopkins Medicine checklist and ASA practice guidelines for central line insertion, for assessment of residents’ practices. First part contained questions regarding the demographic details of residents such as age, gender, year of post graduate training, and parent department, and data related to the procedure such as date and time of procedure, need of CVC discussion during rounds, site of CVC insertion, catheter type and type of procedure (Landmark guided CVC or Ultrasound guided CVC insertion). Second part included direct observational checklist based on checklist provided for prevention of intravascular catheter-associated bloodstream infections to audit the practices of residents during CVC insertion that included: adequate hand hygiene before insertion, adherence to aseptic techniques, using sterile personal protective equipment and sterile full body drape of patient, choosing the best insertion site to minimize infections based on patient characteristics. The parameters observed to be done completely were scored "1" and the items not done were scored "0". The cumulative percentage of performed practices according to checklist, was satisfactory if it was 80% or more and unsatisfactory if it was less than 80%. After initial audit, participants were given pamphlets with checklist incorporating John Hopkins Medicine checklist and ASA practice guidelines for CVC insertion. Re audit was performed one month after the audit, including same participants who participated in initial audit. The results of audit and re-audit were analyzed using SPSS version 25. Mean +/- SD was calculated for quantitative variables and Number (N) percentage was calculated for qualitative variables. Z- Test was applied on proportions of parameters and test scores to calculate Z –score and P value (<0.05 was significant).

Results:

Among the 34 participants, 44% of the participants belonged to Nephrology Department and 56% of participants belonged to Department of Internal Medicine. 32.3% residents were in their first year, 14.7% in second, 14.7 in third year, 17.6% in fourth year and 17.6% in 5th/Final year of training. 47% of the participants were male and 53% were female. Participants were aged between 27 and 34 years old, the median age at the time of audit was 29 years. Landmark guided CVC insertion was performed in Subclavian Vein (73.5%) and Internal Jugular Vein (26.5%). Post audit practices were improved from 73.5% to 94%.

Conclusions:

Our audit found that many of the residents adopted inadequate practices because of lack of proper training and institutional guidelines for CVC insertion. Our re-audit elaborated an improvement in the practices of residents following intervention with educational material. Our study underscores the importance of structured quality improvement initiatives in enhancing clinical practices and patient outcomes.