Improving Central Venous Catheterization

Setting and Study Design

We conducted a prospective, firm‐based clinical trial approved by the institutional review board at Cook County Hospital, a 464‐bed public teaching hospital. We evaluated all central venous catheters inserted by residents on the general medicine service from November 15, 2004, to March 31, 2005. The internal medicine residency program assigns residents to 1 of 3 firms for their entire 3 years of training. We designated 1 firm as the intervention group; the other 2 firms constituted the control group.

Educational Intervention

At the beginning of each 4‐week general medicine ward rotation, intervention‐firm residents attended an educational and simulation laboratory session. Control‐firm residents received the usual ward orientation. We conducted 6 sessions, with total attendance of 40 intervention‐firm residents, or approximately 7 residents per session. A chief medical resident experienced in catheter placement and an attending internist led and supervised each 2‐hour training session. The sessions were conducted at the Simulation Laboratory of Rush University and included a presentation about indications for central venous catheter insertion, insertion techniques, common complications, and practice placing catheters in mannequins. During the hands‐on session, each participant observed the expert insert a triple‐lumen catheter in the mannequin's internal jugular and subclavian veins. Then, with supervision, each participant practiced catheter insertion using recommended infection‐control practices (eg, use of gloves, mask, and large drape, and chlorhexidine skin preparation).

Resident Survey

Before each session, we administered a survey that assessed residents' knowledge of insertion techniques and their confidence in placing catheters at each venous insertion site. To measure change in the confidence level of residents, we distributed an abbreviated survey 2 additional times, immediately after the session and at the end of the study period. We measured confidence with answers to survey questions, which were rated on a 5‐point Likert scale, from strongly disagree to strongly agree. In addition to measuring the change in residents' confidence, the final survey repeated knowledge assessment questions, evaluated residents' attitudes regarding venous insertion sites, and asked about potential strategies to improve insertion practices.

Central Venous Catheter Detection and Monitoring

At the end of each day, residents reported catheter insertions to chief residents during routine sign‐out rounds. If a catheter had been inserted, the chief resident interviewed the resident about type of catheter, venous insertion site, duration of attempt, patient location, immediate complications, number of inserters, inserter attendance at an educational session, inserter specialty, and professional designation (eg, resident, fellow, attending), indication for insertion, and adherence to infection‐control practices. For all insertion attempts, the research team reviewed the medical record and recorded patient characteristics that might influence venous insertion site (eg, thrombocytopenia, coagulopathy, and body mass index) and evaluated patients for insertion‐related complications.

We prospectively monitored patients for mechanical (ie, pneumothorax or hematoma), thromboembolic, or infectious complications. To evaluate for pneumothorax, postinsertion chest radiographs were reviewed by a physician‐investigator, and radiologists' interpretations and progress notes were reviewed. To evaluate for infectious or other mechanical complications, progress notes also were reviewed. We required radiographic confirmation of venous thromboembolism. To categorize potential bloodstream infections, we used Centers for Disease Control and Prevention definitions.9 All medical record and radiograph reviews were performed by investigators who were masked to patient firm assignment. We monitored patients until catheter removal or hospital discharge. After patient discharge, we reviewed the electronic record, including emergency room visits and repeat hospitalizations, for 30 days after the earlier of hospital discharge or catheter removal.

Statistics

Because we were aware that temporary dialysis catheters are sometimes placed in femoral veins to preserve the subclavian or internal jugular venous sites for more permanent tunneled intravascular catheters, our prespecified plans were to compare venous insertion sites between intervention and control groups after excluding temporary dialysis catheters. To more completely describe catheter use, we also collected data on temporary dialysis catheters, and we present the results both with and without inclusion of data on temporary dialysis catheters. If multiple residents attempted to insert a catheter, we would have used the group that the final inserter was in to determine intervention versus control group assignment; however, this never occurred.

To determine resident confidence in inserting catheters, we collapsed the responses of agree and strongly agree and of disagree and strongly disagree into single categories; thus, frequency of agreement was evaluated as a dichotomous outcome. To test whether residents' confidence changed between the 3 surveys, we analyzed responses using the matched‐pair signed rank test, with the initial survey used as the referent.

We dichotomized certain continuous variables using the following cut points: body mass index 30 kg/m²; coagulopathy, international normalized ratio (INR) > 1.5; thrombocytopenia, platelets < 100 10⁹/L. Data were entered into a relational database (Microsoft Access, Microsoft Inc., Redmond, WA) and merged analyzed using Stata software, version 8.2 (Stata Corporation, College Station, TX).

Patient and Catheter Characteristics

Fifty‐four catheters were inserted in 48 patients during the study period, 16 (30%) in the intervention group and 38 (70%) in the control group. Mean number of catheters inserted per resident for each 4‐week rotation was 0.24; therefore, on average, a resident would insert 1 catheter every 4 general‐medicine rotations. Most catheters were inserted between 7:00 _AM and 5:00 _PM; the most common reason for insertion was to administer intravenous medications to a patient without intravenous access, followed by the need for a temporary dialysis catheter. Most catheters were inserted by the medicine team rather than radiology or a subspecialty service (Table 1). Most patient characteristics and reasons for insertion were similar between groups; however, more patients in the control group had thrombocytopenia (Table 1).

Insertion Practices

Femoral venous insertion was the most common type of catheter insertion (67%), followed by internal jugular (26%) and subclavian (7%); there were no differences in insertion site between the intervention and control groups (Table 2). When we excluded temporary dialysis catheters, 39% of central venous catheters were inserted in the internal jugular vein. Although a smaller proportion of catheters inserted by the intervention group were placed in a femoral vein, the difference was not significant (Table 2).

For most insertions, residents reported using sterile gloves (94%) and a large drape (80%); however, most did not report use of a sterile gown (48%), mask (46%), or cap (15%). Residents in the intervention group were more likely to report use of a mask, and there was a trend toward increased use of large drapes (Table 2). No patient characteristics predicted femoral venous insertion (data not shown).

Complications

The most frequent complication was arterial puncture (n = 4); all four occurred during femoral venous insertion attempts. Compared to subclavian or internal jugular venous placement, there was a trend toward more mechanical complications among femoral catheters (Table 3). One episode of clinical sepsis occurred, in an intervention‐group patient who had femoral and internal jugular catheters, and no pneumothoraxes or episodes of venous thromboembolism occurred (Table 3). The overall incidence of bloodstream infection was 2.7 per 1000 central‐line days; there was no difference between the intervention and control groups (9.2 versus 0 per 1000 central‐line days; P = .29).

Survey Responses

Before the educational session, many residents did not recognize that femoral venous catheter insertions had a higher risk of arterial puncture or venous thrombosis (Table 4); by the final survey, residents were more likely to recognize the higher risk of these complications during femoral venous insertions. Most residents recognized the higher risk of infectious complications at the femoral site (Table 4).

Residents overwhelmingly responded that the lecture was useful (95%), that mannequins provided a valuable skill‐building exercise (90%), and that the session should be incorporated into the training program (95%). Immediately after the session, residents had increased confidence about inserting a central venous catheter at any venous site, especially for internal jugular or subclavian insertions. By the final survey, the confidence of residents about inserting catheters in the internal jugular or subclavian veins had returned to baseline but had increased for femoral‐site insertions (Table 4).

Most residents in the intervention group agreed that the educational session motivated them to remove unnecessary catheters, improve insertion‐related infection‐control practices, and place the catheter in an internal jugular or subclavian vein; some agreed because of the educational session, they were less likely to place a central venous catheter. Some reported successfully inserting a central venous catheter in the subclavian or internal jugular vein for the first time (Table 4).

Setting and Study Design

We conducted a prospective, firm‐based clinical trial approved by the institutional review board at Cook County Hospital, a 464‐bed public teaching hospital. We evaluated all central venous catheters inserted by residents on the general medicine service from November 15, 2004, to March 31, 2005. The internal medicine residency program assigns residents to 1 of 3 firms for their entire 3 years of training. We designated 1 firm as the intervention group; the other 2 firms constituted the control group.

Educational Intervention

At the beginning of each 4‐week general medicine ward rotation, intervention‐firm residents attended an educational and simulation laboratory session. Control‐firm residents received the usual ward orientation. We conducted 6 sessions, with total attendance of 40 intervention‐firm residents, or approximately 7 residents per session. A chief medical resident experienced in catheter placement and an attending internist led and supervised each 2‐hour training session. The sessions were conducted at the Simulation Laboratory of Rush University and included a presentation about indications for central venous catheter insertion, insertion techniques, common complications, and practice placing catheters in mannequins. During the hands‐on session, each participant observed the expert insert a triple‐lumen catheter in the mannequin's internal jugular and subclavian veins. Then, with supervision, each participant practiced catheter insertion using recommended infection‐control practices (eg, use of gloves, mask, and large drape, and chlorhexidine skin preparation).

Resident Survey

Before each session, we administered a survey that assessed residents' knowledge of insertion techniques and their confidence in placing catheters at each venous insertion site. To measure change in the confidence level of residents, we distributed an abbreviated survey 2 additional times, immediately after the session and at the end of the study period. We measured confidence with answers to survey questions, which were rated on a 5‐point Likert scale, from strongly disagree to strongly agree. In addition to measuring the change in residents' confidence, the final survey repeated knowledge assessment questions, evaluated residents' attitudes regarding venous insertion sites, and asked about potential strategies to improve insertion practices.

Central Venous Catheter Detection and Monitoring

At the end of each day, residents reported catheter insertions to chief residents during routine sign‐out rounds. If a catheter had been inserted, the chief resident interviewed the resident about type of catheter, venous insertion site, duration of attempt, patient location, immediate complications, number of inserters, inserter attendance at an educational session, inserter specialty, and professional designation (eg, resident, fellow, attending), indication for insertion, and adherence to infection‐control practices. For all insertion attempts, the research team reviewed the medical record and recorded patient characteristics that might influence venous insertion site (eg, thrombocytopenia, coagulopathy, and body mass index) and evaluated patients for insertion‐related complications.

We prospectively monitored patients for mechanical (ie, pneumothorax or hematoma), thromboembolic, or infectious complications. To evaluate for pneumothorax, postinsertion chest radiographs were reviewed by a physician‐investigator, and radiologists' interpretations and progress notes were reviewed. To evaluate for infectious or other mechanical complications, progress notes also were reviewed. We required radiographic confirmation of venous thromboembolism. To categorize potential bloodstream infections, we used Centers for Disease Control and Prevention definitions.9 All medical record and radiograph reviews were performed by investigators who were masked to patient firm assignment. We monitored patients until catheter removal or hospital discharge. After patient discharge, we reviewed the electronic record, including emergency room visits and repeat hospitalizations, for 30 days after the earlier of hospital discharge or catheter removal.

Statistics

Because we were aware that temporary dialysis catheters are sometimes placed in femoral veins to preserve the subclavian or internal jugular venous sites for more permanent tunneled intravascular catheters, our prespecified plans were to compare venous insertion sites between intervention and control groups after excluding temporary dialysis catheters. To more completely describe catheter use, we also collected data on temporary dialysis catheters, and we present the results both with and without inclusion of data on temporary dialysis catheters. If multiple residents attempted to insert a catheter, we would have used the group that the final inserter was in to determine intervention versus control group assignment; however, this never occurred.

To determine resident confidence in inserting catheters, we collapsed the responses of agree and strongly agree and of disagree and strongly disagree into single categories; thus, frequency of agreement was evaluated as a dichotomous outcome. To test whether residents' confidence changed between the 3 surveys, we analyzed responses using the matched‐pair signed rank test, with the initial survey used as the referent.

We dichotomized certain continuous variables using the following cut points: body mass index 30 kg/m²; coagulopathy, international normalized ratio (INR) > 1.5; thrombocytopenia, platelets < 100 10⁹/L. Data were entered into a relational database (Microsoft Access, Microsoft Inc., Redmond, WA) and merged analyzed using Stata software, version 8.2 (Stata Corporation, College Station, TX).

Patient and Catheter Characteristics

Fifty‐four catheters were inserted in 48 patients during the study period, 16 (30%) in the intervention group and 38 (70%) in the control group. Mean number of catheters inserted per resident for each 4‐week rotation was 0.24; therefore, on average, a resident would insert 1 catheter every 4 general‐medicine rotations. Most catheters were inserted between 7:00 _AM and 5:00 _PM; the most common reason for insertion was to administer intravenous medications to a patient without intravenous access, followed by the need for a temporary dialysis catheter. Most catheters were inserted by the medicine team rather than radiology or a subspecialty service (Table 1). Most patient characteristics and reasons for insertion were similar between groups; however, more patients in the control group had thrombocytopenia (Table 1).

Insertion Practices

Femoral venous insertion was the most common type of catheter insertion (67%), followed by internal jugular (26%) and subclavian (7%); there were no differences in insertion site between the intervention and control groups (Table 2). When we excluded temporary dialysis catheters, 39% of central venous catheters were inserted in the internal jugular vein. Although a smaller proportion of catheters inserted by the intervention group were placed in a femoral vein, the difference was not significant (Table 2).

For most insertions, residents reported using sterile gloves (94%) and a large drape (80%); however, most did not report use of a sterile gown (48%), mask (46%), or cap (15%). Residents in the intervention group were more likely to report use of a mask, and there was a trend toward increased use of large drapes (Table 2). No patient characteristics predicted femoral venous insertion (data not shown).

Complications

The most frequent complication was arterial puncture (n = 4); all four occurred during femoral venous insertion attempts. Compared to subclavian or internal jugular venous placement, there was a trend toward more mechanical complications among femoral catheters (Table 3). One episode of clinical sepsis occurred, in an intervention‐group patient who had femoral and internal jugular catheters, and no pneumothoraxes or episodes of venous thromboembolism occurred (Table 3). The overall incidence of bloodstream infection was 2.7 per 1000 central‐line days; there was no difference between the intervention and control groups (9.2 versus 0 per 1000 central‐line days; P = .29).

Survey Responses

Before the educational session, many residents did not recognize that femoral venous catheter insertions had a higher risk of arterial puncture or venous thrombosis (Table 4); by the final survey, residents were more likely to recognize the higher risk of these complications during femoral venous insertions. Most residents recognized the higher risk of infectious complications at the femoral site (Table 4).

Residents overwhelmingly responded that the lecture was useful (95%), that mannequins provided a valuable skill‐building exercise (90%), and that the session should be incorporated into the training program (95%). Immediately after the session, residents had increased confidence about inserting a central venous catheter at any venous site, especially for internal jugular or subclavian insertions. By the final survey, the confidence of residents about inserting catheters in the internal jugular or subclavian veins had returned to baseline but had increased for femoral‐site insertions (Table 4).

Most residents in the intervention group agreed that the educational session motivated them to remove unnecessary catheters, improve insertion‐related infection‐control practices, and place the catheter in an internal jugular or subclavian vein; some agreed because of the educational session, they were less likely to place a central venous catheter. Some reported successfully inserting a central venous catheter in the subclavian or internal jugular vein for the first time (Table 4).

Setting and Study Design

We conducted a prospective, firm‐based clinical trial approved by the institutional review board at Cook County Hospital, a 464‐bed public teaching hospital. We evaluated all central venous catheters inserted by residents on the general medicine service from November 15, 2004, to March 31, 2005. The internal medicine residency program assigns residents to 1 of 3 firms for their entire 3 years of training. We designated 1 firm as the intervention group; the other 2 firms constituted the control group.

Educational Intervention

At the beginning of each 4‐week general medicine ward rotation, intervention‐firm residents attended an educational and simulation laboratory session. Control‐firm residents received the usual ward orientation. We conducted 6 sessions, with total attendance of 40 intervention‐firm residents, or approximately 7 residents per session. A chief medical resident experienced in catheter placement and an attending internist led and supervised each 2‐hour training session. The sessions were conducted at the Simulation Laboratory of Rush University and included a presentation about indications for central venous catheter insertion, insertion techniques, common complications, and practice placing catheters in mannequins. During the hands‐on session, each participant observed the expert insert a triple‐lumen catheter in the mannequin's internal jugular and subclavian veins. Then, with supervision, each participant practiced catheter insertion using recommended infection‐control practices (eg, use of gloves, mask, and large drape, and chlorhexidine skin preparation).

Resident Survey

Before each session, we administered a survey that assessed residents' knowledge of insertion techniques and their confidence in placing catheters at each venous insertion site. To measure change in the confidence level of residents, we distributed an abbreviated survey 2 additional times, immediately after the session and at the end of the study period. We measured confidence with answers to survey questions, which were rated on a 5‐point Likert scale, from strongly disagree to strongly agree. In addition to measuring the change in residents' confidence, the final survey repeated knowledge assessment questions, evaluated residents' attitudes regarding venous insertion sites, and asked about potential strategies to improve insertion practices.

Central Venous Catheter Detection and Monitoring

At the end of each day, residents reported catheter insertions to chief residents during routine sign‐out rounds. If a catheter had been inserted, the chief resident interviewed the resident about type of catheter, venous insertion site, duration of attempt, patient location, immediate complications, number of inserters, inserter attendance at an educational session, inserter specialty, and professional designation (eg, resident, fellow, attending), indication for insertion, and adherence to infection‐control practices. For all insertion attempts, the research team reviewed the medical record and recorded patient characteristics that might influence venous insertion site (eg, thrombocytopenia, coagulopathy, and body mass index) and evaluated patients for insertion‐related complications.

We prospectively monitored patients for mechanical (ie, pneumothorax or hematoma), thromboembolic, or infectious complications. To evaluate for pneumothorax, postinsertion chest radiographs were reviewed by a physician‐investigator, and radiologists' interpretations and progress notes were reviewed. To evaluate for infectious or other mechanical complications, progress notes also were reviewed. We required radiographic confirmation of venous thromboembolism. To categorize potential bloodstream infections, we used Centers for Disease Control and Prevention definitions.9 All medical record and radiograph reviews were performed by investigators who were masked to patient firm assignment. We monitored patients until catheter removal or hospital discharge. After patient discharge, we reviewed the electronic record, including emergency room visits and repeat hospitalizations, for 30 days after the earlier of hospital discharge or catheter removal.

Statistics

Because we were aware that temporary dialysis catheters are sometimes placed in femoral veins to preserve the subclavian or internal jugular venous sites for more permanent tunneled intravascular catheters, our prespecified plans were to compare venous insertion sites between intervention and control groups after excluding temporary dialysis catheters. To more completely describe catheter use, we also collected data on temporary dialysis catheters, and we present the results both with and without inclusion of data on temporary dialysis catheters. If multiple residents attempted to insert a catheter, we would have used the group that the final inserter was in to determine intervention versus control group assignment; however, this never occurred.

To determine resident confidence in inserting catheters, we collapsed the responses of agree and strongly agree and of disagree and strongly disagree into single categories; thus, frequency of agreement was evaluated as a dichotomous outcome. To test whether residents' confidence changed between the 3 surveys, we analyzed responses using the matched‐pair signed rank test, with the initial survey used as the referent.

We dichotomized certain continuous variables using the following cut points: body mass index 30 kg/m²; coagulopathy, international normalized ratio (INR) > 1.5; thrombocytopenia, platelets < 100 10⁹/L. Data were entered into a relational database (Microsoft Access, Microsoft Inc., Redmond, WA) and merged analyzed using Stata software, version 8.2 (Stata Corporation, College Station, TX).

Patient and Catheter Characteristics

Fifty‐four catheters were inserted in 48 patients during the study period, 16 (30%) in the intervention group and 38 (70%) in the control group. Mean number of catheters inserted per resident for each 4‐week rotation was 0.24; therefore, on average, a resident would insert 1 catheter every 4 general‐medicine rotations. Most catheters were inserted between 7:00 _AM and 5:00 _PM; the most common reason for insertion was to administer intravenous medications to a patient without intravenous access, followed by the need for a temporary dialysis catheter. Most catheters were inserted by the medicine team rather than radiology or a subspecialty service (Table 1). Most patient characteristics and reasons for insertion were similar between groups; however, more patients in the control group had thrombocytopenia (Table 1).

Insertion Practices

Femoral venous insertion was the most common type of catheter insertion (67%), followed by internal jugular (26%) and subclavian (7%); there were no differences in insertion site between the intervention and control groups (Table 2). When we excluded temporary dialysis catheters, 39% of central venous catheters were inserted in the internal jugular vein. Although a smaller proportion of catheters inserted by the intervention group were placed in a femoral vein, the difference was not significant (Table 2).

For most insertions, residents reported using sterile gloves (94%) and a large drape (80%); however, most did not report use of a sterile gown (48%), mask (46%), or cap (15%). Residents in the intervention group were more likely to report use of a mask, and there was a trend toward increased use of large drapes (Table 2). No patient characteristics predicted femoral venous insertion (data not shown).

Complications

The most frequent complication was arterial puncture (n = 4); all four occurred during femoral venous insertion attempts. Compared to subclavian or internal jugular venous placement, there was a trend toward more mechanical complications among femoral catheters (Table 3). One episode of clinical sepsis occurred, in an intervention‐group patient who had femoral and internal jugular catheters, and no pneumothoraxes or episodes of venous thromboembolism occurred (Table 3). The overall incidence of bloodstream infection was 2.7 per 1000 central‐line days; there was no difference between the intervention and control groups (9.2 versus 0 per 1000 central‐line days; P = .29).

Survey Responses

Before the educational session, many residents did not recognize that femoral venous catheter insertions had a higher risk of arterial puncture or venous thrombosis (Table 4); by the final survey, residents were more likely to recognize the higher risk of these complications during femoral venous insertions. Most residents recognized the higher risk of infectious complications at the femoral site (Table 4).

Residents overwhelmingly responded that the lecture was useful (95%), that mannequins provided a valuable skill‐building exercise (90%), and that the session should be incorporated into the training program (95%). Immediately after the session, residents had increased confidence about inserting a central venous catheter at any venous site, especially for internal jugular or subclavian insertions. By the final survey, the confidence of residents about inserting catheters in the internal jugular or subclavian veins had returned to baseline but had increased for femoral‐site insertions (Table 4).

Most residents in the intervention group agreed that the educational session motivated them to remove unnecessary catheters, improve insertion‐related infection‐control practices, and place the catheter in an internal jugular or subclavian vein; some agreed because of the educational session, they were less likely to place a central venous catheter. Some reported successfully inserting a central venous catheter in the subclavian or internal jugular vein for the first time (Table 4).