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Barriers to ultrasound guidance for central venous access: a survey among Dutch intensivists and anaesthesiologists.

ABSTRACT: Accumulating evidence shows that ultrasound (US) guidance improves effectiveness and safety of central venous catheter (CVC) placement. Several international guidelines therefore recommend the use of US for placement of CVCs. However, surveys show that the landmark-based technique is still widely used, while the percentage of physicians using US is increasing less than expected. The goal of this study was to investigate current practice for central venous catheterization in anaesthesiology and intensive care in the Netherlands, identify barriers for further implementation of US guidance and to evaluate whether personality traits are associated with the choice of technique. We conducted a web-based national survey, distributed among members of the Dutch societies of anaesthesiology (NVA) and intensive care (NVIC). The survey contained questions regarding physician and hospital characteristics, frequency of US use and reasons for use or non-use, as well as the NEO-FFI-3, a validated, translated questionnaire to characterize personality traits according to the 'Big Five' concept. Response rate was 22% (506/2291), of which 400 had also the personality questionnaire complete. Ultrasound guidance was used always or almost always in 68%; barriers for US use were working in a non-academic non-teaching hospital, providing cardiac anaesthesia and more years of physician experience. Reasons for not using US were perceived lack of benefit, increased procedure time, lack of US equipment and fear of loss of landmark technique skills. 13% of respondents had never experienced a complication during CVC placement, and 67% knew of a complication occurring the past year at their department. Ultrasound was thought not to be able to prevent the complication in half of these cases. Of the personality traits, only neuroticism and extraversion showed a minor positive association with US guidance. A majority of anaesthesiologists and intensivists uses US guidance for CVC placement, but a significant proportion of physicians still prefers the landmark technique. Most arguments from respondents against US guidance can be challenged. Personality traits most likely do not play a major role in the acceptance of US guidance for central venous catheterization. A potential intervention to increase US use could be formalizing local hospital policies mandating compliance with US guidance. Future research can perhaps focus on cognitive biases that currently limit more widespread use of US guidance.

SUBMITTER: Scholten HJ

PROVIDER: S-EPMC6823316 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Barriers to ultrasound guidance for central venous access: a survey among Dutch intensivists and anaesthesiologists.

Scholten Harm J HJ Ten Bloemendal Esther E Botter Bente B Korsten Hendrikus H M HHM Bouwman R Arthur RA

Journal of clinical monitoring and computing 20190119 6

Accumulating evidence shows that ultrasound (US) guidance improves effectiveness and safety of central venous catheter (CVC) placement. Several international guidelines therefore recommend the use of US for placement of CVCs. However, surveys show that the landmark-based technique is still widely used, while the percentage of physicians using US is increasing less than expected. The goal of this study was to investigate current practice for central venous catheterization in anaesthesiology and i ...[more]

PMID: 30661195

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Project description:IntroductionOver the past decade, medical students have witnessed a decline in the opportunities to perform technical skills during their clinical years. Ultrasound-guided central venous access (USG-CVA) is a critical procedure commonly performed by emergency medicine, anesthesia, and general surgery residents, often during their first month of residency. However, the acquisition of skills required to safely perform this procedure is often deficient upon graduation from medical school. To ameliorate this lack of technical proficiency, ultrasound simulation models have been introduced into undergraduate medical education to train venous access skills. Criticisms of simulation models are the innate lack of realistic tactile qualities, as well as the lack of anatomical variances when compared to living patients. The purpose of our investigation was to design and evaluate a life-like and reproducible training model for USG-CVA using a fresh cadaver.MethodsThis was a cross-sectional study at an urban academic medical center. An 18-point procedural knowledge tool and an 18-point procedural skill evaluation tool were administered during a cadaver lab at the beginning and end of the surgical clerkship. During the fresh cadaver lab, procedure naïve third-year medical students were trained on how to perform ultrasound-guided central venous access of the femoral and internal jugular vessels. Preparation of the fresh cadaver model involved placement of a thin-walled latex tubing in the anatomic location of the femoral and internal jugular vein respectively.ResultsFifty-six third-year medical students participated in this study during their surgical clerkship. The fresh cadaver model provided high quality and lifelike ultrasound images despite numerous cannulation attempts. Technical skill scores improved from an average score of 3 to 12 (p<0.001) and procedural knowledge scores improved from an average score of 4 to 8 (p<0.001).ConclusionThe use of this novel cadaver model prevented extravasation of fluid, maintained ultrasound-imaging quality, and proved to be an effective educational model allowing third-year medical students to improve and maintain their technical skills.

Project description:BACKGROUND:Ultrasound guidance for central venous catheterization is a commonly used alternative to the conventional landmark method. Because from the German perspective, the cost-effectiveness of ultrasound guidance is unclear, this study examined the cost-effectiveness of ultrasound guidance versus the landmark method for adults undergoing a central venous catheterization. METHODS:A decision-tree based model was built to estimate the costs of averted catheter-related complications. Clinical data (e.g. arterial puncture, failed attempts) were obtained from a Cochrane review and a randomized controlled trial, whilst information about cost parameters were taken from a German hospital of maximum care. The analysis was conducted from the perspective of the German Statutory Health Insurance. Results were presented as incremental cost-effectiveness ratios. To assess the parameter uncertainty, several sensitivity analyses were performed (deterministic, probabilistic and with regard to the model structure). RESULTS:Our analysis revealed that ultrasound guidance resulted in fewer complications per person (0.04 versus 0.17 for the landmark method) and was less expensive (€51 versus €230 for the landmark method). Results were robust to changes in the model parameters and in the model structure. Whilst our model population reflected approximately 49% of adults undergoing a central venous catheterization cannulation per year, structural sensitivity analyses (e.g. extending the study cohort to patients at higher baseline risk of complications, pediatric patients, or using real-time/indirect catheterization) indicated the cost-effectiveness of ultrasound guidance for a broader spectrum of patients. The results should be interpreted by considering the assumptions (e.g. target population) and approximations (e.g. cost parameters) underpinning the model. CONCLUSIONS:Ultrasound guidance for central venous catheterization averts more catheter-related complications and may save the resources of the German Statutory Health Insurance compared with landmark method.

Project description:ObjectiveEmerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts.MethodsWe performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.ResultsTwenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients.ConclusionThirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.

Dataset Information

Barriers to ultrasound guidance for central venous access: a survey among Dutch intensivists and anaesthesiologists.

Publications

Barriers to ultrasound guidance for central venous access: a survey among Dutch intensivists and anaesthesiologists.

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