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Research Letter | Less Is More

Reduction of Central Venous Catheter Use in Medical Inpatients Through Regular Physician Audits Using an Online Tool FREE

Emily G. McDonald, MD1,2; Todd C. Lee, MD, MPH1,2,3
[+] Author Affiliations
1Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
2McGill Centre for Quality Improvement, Montreal, Quebec, Canada
3Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
JAMA Intern Med. 2015;175(7):1232-1234. doi:10.1001/jamainternmed.2015.1292.
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Published online

Central venous catheters (CVCs) facilitate secure access in critically ill patients and allow for the administration of caustic substances. Potential harms include bloodstream infections1 and thromboembolism.2 A recent study showed that 21.2% of physicians were unaware that their patient had a CVC3 and therefore were incapable of making judicious decisions about catheter retention. At our center, we suspected that physicians were frequently unaware of the CVCs; therefore, we created a system to ensure that CVCs were regularly reevaluated.

The study was conducted in two 26-bed internal medicine clinical teaching units in a 517-bed hospital. Baseline data were collected from January 21, 2013, through March 27, 2013. Thereafter, we implemented the intervention from June 1, 2013, through December 1, 2014.

Senior residents evaluated all their patients once weekly for the presence of CVCs and anonymously recorded the number and their respective indications (starting August 1, 2013) using an online tool (Figure). The tool prompted residents to consider whether each CVC was necessary and to discuss with their teams whether to retain the CVC. Overall auditing adherence was 70%. The prevalence of CVCs and their indications were discussed with the teams monthly.

Place holder to copy figure label and caption
Figure.
Online Tool

Online tool used for physician audits of central venous catheters (CVCs) and for data collection. IV indicates intravenous; PICC, percutaneous inserted central catheter; and TPN, total parenteral nutrition.

Graphic Jump Location

Central venous catheters were defined as nontunneled, nondialysis catheters in jugular, subclavian, or femoral veins, or peripherally inserted central catheters. Infections associated with the CVC were assessed using standard criteria4 and standardized per 10 000 patient days. McGill University Health Centre Institutional Review Board approval was waived, as this process was considered best practice.

Rate differences between CVC use per 100 patient audit days and infections associated with the CVC per 10 000 patient days were compared before and after intervention using the z test and inverse variance rates. Rates among junior (≤5 years’ experience) and nonjunior (>5 years’ experience) faculty were similarly compared.

After the intervention, the rate of CVCs per 100 patient days decreased from 13.1 to 7.0 (51 CVCs in 390 patient days audited vs 167 CVCs in 2392 patient days audited, P < .01). Overall, junior faculty had lower weighted mean CVC rates than did nonjunior faculty (4.8 vs 8.9 per 100 patient audit days, P < .01) (Table). There was no difference in the annual rates of infections associated with the CVC before and after the intervention (2.9 vs 1.1 per 10 000 patient days, P = .25).

Table Graphic Jump LocationTable.  Rates of CVC Use by Attending Physician

Of 161 postintervention CVCs, 107 (66.5%) had an indication recorded, including antibiotic administration (48.5%), ease of drawing blood for testing (20.6%), chemotherapy (12.1%), venous access in case of patient deterioration (11.2%), and parenteral nutrition (5.6%).

We demonstrated a 46.6% reduction (95% CI, 27.0%-61.0%) in CVC use through regular auditing requiring minimal effort. There remains room for improvement, as audit adherence was imperfect and one-third of CVCs were indicated for ease of drawing blood for testing or venous access in case of deterioration. As the Choosing Wisely movement reduces unnecessary testing, and both point-of-care ultrasound and interosseous devices facilitate emergency venous access, we hope that fewer CVCs remain for these indications.

The differences between junior and nonjunior faculty are interesting. We hypothesize that junior faculty may have had lower CVC rates because they may be more likely to instruct their senior residents to remove CVCs because of increased comfort with their own ability to subsequently reinsert them if necessary.

Our study was limited to medical inpatients in a single center; consequently, it may lack generalizability. We also implemented our program rapidly to limit harm and did not accrue sufficient baseline data to permit time-series analysis. Our results may consequently be biased by overuse during the baseline assessment. Despite these limitations, we describe a logical, inexpensive intervention that is without risk to the patient.

We suggest that such interventions, which involve the concept of medical mindfulness, can be one effective means of reducing use of CVCs. Our clinical teaching unit has successfully used a similar method of targeted reassessment to improve antibiotic use5 and believes this method could be adapted to Foley catheters.6,7 Through consciously striving to act as the stewards of iatrogenic risk, we believe physicians can optimize patient safety.

Corresponding Author: Todd C. Lee, MD, MPH, Division of General Internal Medicine, McGill University Health Centre, 687 Pine Ave W, Room M603B, Montreal, QC H3A1A1, Canada (todd.lee@mcgill.ca).

Published Online: May 4, 2015. doi:10.1001/jamainternmed.2015.1292.

Author Contributions: Dr Lee had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lee.

Administrative, technical, or material support: All authors.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Ramy R. Saleh, MD, Department of Medicine, McGill University, reviewed the manuscript. We thank the resident physicians who collected the data in the context of patient care, as well as our attending physicians, who strive to provide patients with the best care. None of the contributors were compensated.

Chopra  V, O’Horo  JC, Rogers  MA, Maki  DG, Safdar  N.  The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2013;34(9):908-918.
PubMed   |  Link to Article
Chopra  V, Anand  S, Hickner  A,  et al.  Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382(9889):311-325.
PubMed   |  Link to Article
Chopra  V, Govindan  S, Kuhn  L,  et al.  Do clinicians know which of their patients have central venous catheters? a multicenter observational study. Ann Intern Med. 2014;161(8):562-567.
PubMed   |  Link to Article
Horan  TC, Andrus  M, Dudeck  MA.  CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-332.
PubMed   |  Link to Article
Lee  TC, Frenette  C, Jayaraman  D, Green  L, Pilote  L.  Antibiotic self-stewardship: trainee-led structured antibiotic time-outs to improve antimicrobial use. Ann Intern Med. 2014;161(10)(suppl):S53-S58.
PubMed   |  Link to Article
Al-Abri  M, Wong  BM, Leis  JA.  A urinary catheter left in place for slightly too long: a teachable moment. JAMA Intern Med. 2015;175(2):163.
PubMed   |  Link to Article
Kalra  R, Kraemer  RR.  Urinary catheterization—when good intentions go awry: a teachable moment. JAMA Intern Med. 2014;174(10):1547-1548.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Online Tool

Online tool used for physician audits of central venous catheters (CVCs) and for data collection. IV indicates intravenous; PICC, percutaneous inserted central catheter; and TPN, total parenteral nutrition.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Rates of CVC Use by Attending Physician

References

Chopra  V, O’Horo  JC, Rogers  MA, Maki  DG, Safdar  N.  The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2013;34(9):908-918.
PubMed   |  Link to Article
Chopra  V, Anand  S, Hickner  A,  et al.  Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382(9889):311-325.
PubMed   |  Link to Article
Chopra  V, Govindan  S, Kuhn  L,  et al.  Do clinicians know which of their patients have central venous catheters? a multicenter observational study. Ann Intern Med. 2014;161(8):562-567.
PubMed   |  Link to Article
Horan  TC, Andrus  M, Dudeck  MA.  CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-332.
PubMed   |  Link to Article
Lee  TC, Frenette  C, Jayaraman  D, Green  L, Pilote  L.  Antibiotic self-stewardship: trainee-led structured antibiotic time-outs to improve antimicrobial use. Ann Intern Med. 2014;161(10)(suppl):S53-S58.
PubMed   |  Link to Article
Al-Abri  M, Wong  BM, Leis  JA.  A urinary catheter left in place for slightly too long: a teachable moment. JAMA Intern Med. 2015;175(2):163.
PubMed   |  Link to Article
Kalra  R, Kraemer  RR.  Urinary catheterization—when good intentions go awry: a teachable moment. JAMA Intern Med. 2014;174(10):1547-1548.
PubMed   |  Link to Article

Correspondence

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