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Quality & Patient Safety

Research Snapshot Theater: Quality and Patient Safety/Procedures, Adult and Pediatric

(1374) Documentation of Ultrasound Guidance During Central Venous Catheter Insertion

Sunday, February 23, 2025
12:15pm – 1:15pm Eastern Time
Location: Connections Central - RST 14

    First Author(s)

  • Sam Biniazan, DO, MA (he/him/his)

    USA

    • Co-Author(s)

  • Matthew Zackoff, MD, MEd

    Associate Medical Director, Program Director, Attending Physician, Assistant Professor
    Cincinnati Children's Hospital Medical Center
    Cincinnati, Ohio, United States

  • ES

    Erika Stalets, MD, MS

    Attending Physician
    Cincinnati Childrens Hospital Medical Center, United States

  • MM

    Marc Mecoli, MD

    Attending Physician, Assistant Professor
    Cincinnati Children's Hospital Medical Center, United States

  • AL

    Andrew J. Lautz, MD

    Associate Director, Attending Physician, Assistant Professor
    Cincinnati Children's Hospital Medical Center, United States

Introduction: Point-of-care ultrasound is becoming the standard of care for children who undergo central venous catheter (CVC) insertion in the Pediatric Intensive Care Unit (PICU). The safety benefits of procedural ultrasound rely in part on confirming correct central venous guidewire placement. We led a quality improvement initiative to confirm and document guidewire placement prior to dilation for non-emergent CVC insertions. Our main objective was to document guidewire placement in two planes (cross-sectional and longitudinal) for ≥ 90% of non-emergent CVCs.

Methods: The study included non-emergent CVC insertions into the internal jugular, femoral, and subclavian veins between 7/1/23 and 6/30/24. We developed a process for capturing and uploading images from clinical ultrasound machines into the electronic health record (EHR) and provided education to proceduralists and nurses. Tracking and feedback was captured via REDCap surveys from proceduralists, including if images were captured, if guidewire repositioning was required, and obstacles encountered, e.g., forgot, technical issue, emergency CVC placement, or uncertain. PDSA cycles focused on continued education and reminders, individualized feedback, technical troubleshooting, and monthly individual and aggregate data reviews. A Simplified Failure Modes and Effects Analysis (sFMEA) informed our Key Driver Diagram (KDD) and identified improvement opportunities for focused intervention. A Pareto Chart of process barriers identified further areas for improvement.

Results: In total, 147 non-emergent CVCs were performed. Both compliance (percentage of procedural ultrasound orders entered) and success rates (percentage of imported images) improved: 53% to 83% and 20% to 50%, respectively. Pausing for image capture led to correct repositioning of guidewire in three occurrences. Our sFMEA and KDD identified five key drivers and 12 interventions. The REDCap survey and Pareto Chart identified troubleshooting education and reminders as primary areas for targeted interventions.

Conclusions: Documenting ultrasound confirmation of guidewire placement in the EHR during non-emergent CVC placement is feasible in the PICU. PDSA cycles and feedback can improve both compliance and success rates. Common obstacles were technical issues and need for emergent CVC insertion.