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! 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