Transcript - 6th Anesthesia & Critical Care Conference

Internet and Simulation-Based
Training and Competency Program
for
Real-Time Ultrasound-Guided
Central Venous Catheter Placement
Study and Hospital-Wide Implementation
Gyorgy Frendl, MD PhD, FCCM
Associate Professor of Anesthesiology and Critical Care, Harvard Medical School
Director of Research, Surgical Critical Care, Brigham and Women’s Hospital
November 21-22, 2014
Kuwait
Prior Status / Complication Rates
How Many CV Catheters are Placed Yearly?
• OR
• ICUs
–
–
–
–
–
Surgical ICUs
MICU
CCU
Neuro ICUs
Cardiac surg. ICU
• ED
• Cath Lab
• Dialysis
1,992 (2007)
650++
250
150-200
30-50
30-50
100 +/-
300+
300+
• IR
TOTAL number of central venous catheters/year: 4,000 +
How Many CV Catheters Do We Place?
What is The True Incidence?
2005-2008 billing data
Total
# of CV
Catheters
DVT
Incidence
(%)
Infec
tion
Incidence
(%)
PTX
Incidence
(%)
855
20
2.4
26
3.0
38 4.5
2009 3 months focused survey data
Total
# of CV
Lines
DVT
Incidenc
e (%)
Infec
tion
Incidence
(%)
PTX
Incidence
(%)
54
6
11.1
1
1.9
5
9.25
Issues and Complications
• 53.3% failed first attempt
• 21.5% of patients had some adverse events
– 4.2%: two adverse events; 1.5%: three
– PTX: 9.6%, 2X more common with multiple attempts
• 75-80% pts had 2 or more risk factors for high risk
placement
• 1.25-1.8 fold risk of complications with repeated attempts
for all complications
Problems We Identified
Despite the availability of US, its use is haphazard, due to the lack of formal
training of the operators (BWH SICU experience)
Problems
•
Variable hardware
•
Lack of standardized US exam
•
Solutions
•
•
•
Lack of training
•
•
Variable practices
•
Lack of hospital-wide reporting,
surveillance, quality control
•
•
Standardized US machine BWHwide
Standardized the US exam
Standardized training content and
format
Simulation-based training and
competency testing
Standardize practices around ORs
and ICUs
To be developed preferably in ACD
(electronic medical records)
Evidence for the Use of US for CVC
Placement
Status in USA
Status at BWH
• More than 5 million placed in
annually
• Overall complications: app. 1520%
• Severe complications: 5-12%
• Initially no data on how many we
placed
• No data on rate of complications:
prior to 2005
• Severe complications: adverse
events reporting + root cause
analysis
• Related to line infections: hospital
wide efforts since 2001
• Additional (late) complications:
line infection, DVT, stenosis
Use for all indications are increasing !
•
•
•
Access:
– Parenteral nutrition; Delivery of vasoactive agents, fluids, blood products, chemoRx; Difficult
peripheral access, Cardiopulmonary arrest; Need for longer term access for medication delivery
Diagnostic:
– Hemodynamic monitoring; Monitoring oxygenation (sepsis); Repeat blood sampling; Monitor
response to treatment
Intervention (Hemodialysis or plasmapheresis; Temporary pacing)
Approaches to CV Catheter Placement
• Landmark technique
• Ultrasound-assisted
– US doppler
– Real-time two-dimensional (Dynamic) US
• Two-handed vs. three-handed technique
– X marks the spot (static) US assessment only
US guidance is considered to be one of eleven practices
that can significantly improve patient care (by AHRQ)
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD, Agency for
Healthcare Research and Quality, 2001
Patient Safety
• Agency for Healthcare Research & Quality:
• Main Findings:
One of 11 practices - should be
implemented to improve patient safety
“Use of real-time ultrasound
guidance during central line
insertion to prevent complications.”
–Ultrasound use is associated with: decreased placement
failures, decreased complications, & decreased number of
attempts until successful line placement.
–Most favorable scenario: real-time ultrasound use by
inexperienced operators.
http://www.ahrq.gov/clinic/ptsafety/
The National Institute for Clinical
Excellence (NICE) in the UK:
 Meta-analysis of US use for central IJ access compared to the
landmark technique:
– 86% decreased failed catheter placement
– 41% decreased failure on first attempt
– 57% decreased complications
 Fewer attempts (average 1.5) to successful catheterization
 Less time needed (average 69 sec)
 Limited data suggests benefits for US use for subclavian,
femoral CVC, & for infants.
BMJ 2003:327;361-67.
http://www.nice.org.uk/pdf/ULD_assessment_report.pdf
SOAP-3
Primary Outcome: Overall success
Dynamic
Static
Landmark
(1.3-7)
vs.
vs.
Secondary Outcomes: First attempt success, # attempts, time to
cannulation, & complication rate
vs.
vs.
(not significant)
Crit Care Med
2005:33(8);1764-69.
Anatomic Variability of IJ Vein
• Study 1: 8.5% of patients had abnormal IJV anatomy: small fixed
IJV: 3%, no right IJV: 2.5%, an IJV medial to the carotid: 2%, and an
IJV lateral to the carotid with no overlap: 1%.
• Study 2: 8.6% of US exams had abnormal IJV anatomy: no IJV on
one side: 3.1%, transposition with the carotid: 0.6%, thrombosis:
0.6%. 4.3% had IJ vein <5mm in diameter, making IJ catheter
placement very difficult.
• Study 3:
V
V
V
A
A
A
V
A
A
V
3. Gordon et.al., JVIR 1998; 9:333
2. Milling TJ et al. Crit Care Med 2005:33(8);1764-69.
1. Denys BG, Uretsky BF. Crit Care Med 1991; 19: 1516-1519.
Summary of Benefits of Ultrasound







Helps find best site/ side to attempt CVC.
Use a single needle technique with real-time ultrasound.
Increases successful placement on first attempt.
Decreases number of attempts before successful placement.
Decreases complications.
Reduces time required.
Currently, the best documentation
of all benefits is for IJ & femoral
CVC placement.
Internal jugular
Ultrasound Augments Landmarks
•
Non-sterile evaluation with US to:
– Assess patency
– Choose optimal site
•
•
Enhances understanding of normal anatomy, identifies variant anatomy.
Clarifies the relative position of the needle, vein, & surrounding structures.
How could We Avoid This?
Convert this anatomy
to
this anatomy
IJV
CCA
45+ degree
<25 degree
The Ultimate Goal
Improve Patient Safety for All BWH CVC Placement
by Providing
te
und
CUs
Rs
Harvard Medical
School
Bedside US for
routine use in all
BWH ICUs and
ORs
A structured,
A standardized
standardized
testing and
training program competency
Reporting
Studying
practices and
outcomes
Real-time two-dimensional (Dynamic) US
Two-handed vs. three-handed technique
Web-based training
STRATUS based simulation/competency
By creating a quality control (QC)
mechanism for professional reads of
bedside US recordings, and for QC
review and ongoing training
Uniform US Machines for All BWH Locations
ICUs
ORs
ED
STRATUS
IR
Cath lab
OB
Training Program Design and Goals
Internet-Based Training
Primary Goals & Objectives
HealthStream Training Program
1. To improve patient safety & care
using Ultrasound guided central line
placement.
2. To teach the use & interpretation of
Ultrasound imaging as an adjunct to
enhance patient landmarks & the
anatomic knowledge of the operator.
Ultrasound Training - Content Outline
CVC Line Infection Prevention Video
BWH Standard Sterile Technique Instructions
Ultrasound Lecture Content Outline
1.
Introduction
2.
Ultrasound & Patient Safety
3.
Ultrasound Introduction
4.
SonoSite System
5.
Ultrasound for Vein Assessment
6.
Ultrasound use for Central Lines: practical aspects
& instruction
Training and Skill Testing in
The STRATUS Center
HealthStream Training Program
Standardized US Exam for Guided CVC Placement:
Images Required to be Viewed and Saved
1. 2D mode dual image with
open & compressed vein
2. Doppler mode of vein
4. Needle entering the vein
5. Guidewire in the vein
3. Doppler mode of artery
6. Catheter in vein
Characteristics of Normal Veins
2D Imaging
• Thin (invisible) & smooth wall.
• Anechoic (black) lumen (except with venous
stasis).
• Compressible with a small amount of
pressure (best tested with transverse
images).
• Valves are present (increasing in number
distally out the extremities).
• Diameter of large veins increases with deep
inspiration or valsalva.
Spectral & Color Doppler
• Spontaneous flow (medium & large veins).
• Phasic non-pulsatile flow (large veins).
• Flow ceases with the Valsalva maneuver.
• Flow can be augmented with distal
compression.
• Flow is unidirectional (toward the heart).
Quiet Respiration
Valsalva
Hatfield and A. Bodenham. Br J Anaesth 1999; 82: 822-6.
Abnormal Images:
Abnormal
Images
Abnormal Images
Thrombus Developing In IJV
small vessel
Small, non-distendible IJ:
multiple prior line attempts
using the landmark technique at
this vessel had hit the patient’s
carotid artery.
Some flow
in center
No flow =
Thrombus
Hatfield and A. Bodenham. Br J Anaesth 1999; 82: 822-6
Optimal Patient Head Positioning
IJ Vein Stenosis
v
v
v
v
A
• Turning the patient’s head more or less from
midline can increase the separation between the IJ
vein & the carotid artery, decreasing the chances
of an arterial puncture.
• It is recommended that you perform this maneuver
just prior to placing the needle to access the vein.
V
A
A
IJ vein stenosis. Selected transverse images from
cephalad (left) to caudad (right) demonstrating progressive
luminal narrowing of the IJ vein (arrow). It might be
V
V
50+ degrees
Dangerous

V
A
about 30 degrees
V
A

A
0-15 degrees
Much Safer
US Training and Competency Study
Design
Randomization (n=133)
(Web : Class)
Online
Knowledge Test
Classroom Lecture
& Hands-on Practice
(n= 65)
Invitations to
participate offered to
residents, fellows
and staff from
Anesthesia, Surgery,
ED, Renal &
Pulmonary.
Competency
Practical Exam
in STRATUS Center
Online Narrated Lecture
& Demonstration Video
(n=68)
Summary
• US guidance improves the safety of CVC placement,
and should be a standard practice
• Unskilled users are at higher risk for causing
complications
• Standardized training, supervision of trainees, and
standardized procedure is essential
• US use:
– Clearly identify artery and vein (2D and pulse wave Doppler)
– Position patient and CVC location so the isolation of artery and
vein is optimal
– Always verify the presence of the guide wire in the vein (and not
in the artery) before placing larger bore catheter
– Confirm venous placement of the catheter by US visualization
– Maintain sterile technique throughout
A System for Hospital-Wide
Implementation
Process of BWH US Training and
Certification
Step 1
Step 2
HealthStream
Training Module
HealthStream
Knowledge Test
• Narrated
PowerPoint
• Demonstration video
Fail
Review Training Module &
Retake Knowledge Test until
Pass
Pas
s
• 35 Multiple
Choice Questions
Schedule STRATUS
Test Session
BWH Certification for
US-guided CVC
placement
Final Certification
Step 3
STRATUS
Set number (10) of supervised
line placements without complications
for trainees
(Supervised by Super-Users, and documented)
Retake STRATUS Hands-on
Practice & Testing
Pass- 90%
Remedial pathway
Remedial Hands-on US
Training with Instructor
Hands-on
Practice &
Testing
BWH-Wide Implementation
Use of US Recommended Practice – 2009
Use of US Standard of Care – 2011
• Number of MDs and physician extenders trained annually: 350-400
• Total number trained since 2009 is > 2,000
Number of Staff Needed to be Trained Initially: 586 +
Anesthesiology, Perioperative
& Pain Medicine
Total: 259
Staff: 106
Others: 8
Residents: 111
Fellows: 34
90% complete
Emergency Medicine
Staff: 37
Residents: 60
Total: 97
40% complete
Medicine
Cardiovascular Medicine
• Cath Lab•
Total: 73
General- Residents: 50
Cardiac Surgery- Fellows:
20% complete
General and GI Surgery
Thoracic Surgery - Fellows: 9
Trauma, Burn and Critical CareStaff:10
Staff:
CCU
Staff:
Fellows: 6
Fellows: 16
Pulmonary & Critical Care Medicine
•
Surgery
Total: 133 +
Medical ICU
Staff:16 Fellows:9-10 Res:45 (65)
10% complete
Renal
Staff: 10
Fellows: 10
General Medicine
Infectious Disease
Fellows: 1-2
Vascular Surgery- Fellows: 2
Neurological Surgery/Neurology
9C & 9D ICU
Total: 24
Staff: 5
Fellows: 9
Residents: 10
0% complete
Obstetrics and Gynecology
Phase I
Phase 2 Phase 3
Comprehensive Data Collection
QA/QC
Outcomes Surveillance, Quality Assurance/Quality Control
Infrastructure
BWH CMO, Senior Leadership / CCE
BWH-wide US Guided
CVC Program
Input from ACD
Electronic medical records
For every CV catheter placed
Regular Reporting
Thrombosis
Surveillance
Infection Control
Surveillance
For CV catheter-related
DVT’s
For CV catheter-related
infections
CV catheter-related major
complications
Pneumothorax
Surveillance
BWH Radiology
Balanced Scorecard
Credentialing
For CV catheter-related
pneumothoraces
Medicine
Service
Standardized BWH Training
Standardized Insertion Procedure
Basic Training
1.
2.
BWH Prevention of Central Line-Associated Bloodstream
Infections
a. Duration: approx 1 hour
b. Medium: HealthStream
c. Description: Focus on the Standard Sterile Technique
used in CVC placement.
d. Responsible physician: Dr. Shannon McKenna
All Services
(excluding
Medicine)
•
Mandatory Simulation Training (Stratus Center)
– Attendings and Residents
• Insertion Technique (Basic technique based on landmarks and standard BWH
sterile technique)
• US Guided CVC Training Program
•
Basic Central Venous Catheter (CVC) Placement Training
a. Duration: 1+ hour
b. Medium: didactic lecture and Simulation
•
c. Description: During June-July Intern Orientation Skills
•
Course. CVC placement following the “landmark
technique - didactic lecture followed by hands on practice
d. Responsible physician: Dr. Anthony Massaro


Mandatory Senior (Attending, Fellow, >PGY-2 resident) Supervision
–
–
–
–
–
OR
ED
ICU
Floors
IR
Anesthesiologist / Surgeons
ED Attending
Critical Care Intensivist
Critical Care Intensivist / Nocturnists
Interventional Radiologist
Mandatory US Guidance – July 2011
New methods of mandatory post-insertion confirmation – July 2011


Ultrasound Training
3.
4.
BWH Ultrasound Guided Central Venous Catheter Placement
Program
a. Duration: 3 hours
b. Medium: HealthStream and Simulation – Based Skills
Test
c. Description: Delivered prior to when trainee is required
to place CVCs. Includes a STRATUS Simulation-Based
Skills Test and a HealthStream course. The
HealthStream course contains the following components:
i. A Narrated Lecture (40 min)
ii. Demonstration Video of US guided CVC
placement (30 min)
iii. Video of Standard Sterile Technique for US
guided CVC placement (10 min)
iv. Multiple-Choice Knowledge Test (30 min)
d. Responsible physician: Dr. George Frendl
STRATUS Simulation- Ultrasound CVC Practice Session
a. Duration: 2 hours
b. Medium: Simulation
c. Description: STRATUS hands-on seccion.
d. Responsible physician: Dr. Sally Wang
Standardized CVC Confirmation
Mandatory Post-insertion Confirmation - July 2011
•

Primary

– Ultrasound confirmation at bedside
– Chest XR Film
• Central tip position
• R/o pneumo/hemothorax
•
Secondary
– Venous Blood Gas
– Transduced venous pulse wave

Training and Competency Program for the
Use of Point-of Care Real-Time Ultrasound-Guidance
for Central Venous Catheter Placement
Participants
Surgical Critical Care
Vascular Ultrasound Laboratory
Kim Matzie, MD
Ian Shempp, BS
Lauren Philbrook, BS
Christia Panizales, BS
Shay Hershkowitz, BS
Gyorgy Frendl, MD PhD
Debra Hand, MS
Marie Gerhard-Herman, MD
STRATUS Simulator Center
Andrew Camerato
Stephen Poole
Mike Trioli
Steve Nelson , MS
Chuck Pozner, MD
BWH Educational Technology
Anne-Marie Shipley, MS
Erlyn Ordinario
Debrah Leven, MBA
Balanced Scorecard/ CCE
Departmental Super Users
Allan, Kachalia, MD, MPH
Funded by
•Partners Educational Innovation Initiative
•Good Samaritan Foundation
•Friends of BWH Foundation
•BWH STAR (Surgical Critical Care Translational Research) Center
THANK YOU!
COMMENTS ARE WELCOME!