(1075) Breaking Barriers: Causes of Low Utilization of Ultrasound-Guided Subclavian Vein Cannulation

Introduction: For decades, ultrasound-guided subclavian central venous cannulation (UGSCV) has been underutilized despite decreased rates of malposition and pneumothorax when compared to landmark based subclavian vein cannulation (SCV). This project seeks to understand the barriers to UGSCV utilization in the surgical intensive care unit (SICU) and opportunities to increase use.

Methods: 6-months of retrospective chart review in SICU (January-June 2023) confirmed UGSCV usage is suboptimal. SICU faculty, fellows, and advanced practice practitioners (APPs) participated in semi-structured interviews regarding their perception and performance of UGSCV. They also completed a best-worst scaling (BWS) survey through Sawtooth Discovery to elucidate preferences affecting central venous catheter (CVC) site selection. Transcribed interviews were coded in NVivo using a pre-existing adapted thematic codebook on UGSCV utilization. Codes were then categorized into themes, and a total unduplicated reach and frequency (TURF) analysis performed.

Results: In the review period (n=293), UGSCV comprised 23% of CVCs placed. APPs placed 22% of all CVCs, but only 7% of SCV lines. CVC malposition and pneumothorax was seen in 11% of SCV lines and 15% of internal jugular (IJ). Associated in-hospital mortality based on CVC insertion site was 23% in the SCV group, 30% for internal jugular, and 40% for femoral sites. Lack of comfort and lack of opportunity were identified as major barriers in both the interviews (n=13) and surveys (n=33). Prevalent themes included “no current standard of training,” “fear of complications,” and “factors decreasing subclavian use.” Providers saw UGSCV as unfamiliar, leading to increased cognitive stress and unease. Mitigation strategies identified from qualitative analysis and TURF analysis suggest increasing faculty support (troubleshooting), allowing for closer supervision, and increasing opportunities to place UGSCV.

Conclusions: Beyond the barriers, standardized UGSCV education with direct faculty support/supervision as well as skill assessment through a mastery learning checklist could increase both insertion and supervision comfort. Increasing comfort should lead to increased opportunities for UGSCV with the greatest opportunity for change with APPs. Thoughtful implementation will be key to success.