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Original Research |

Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational StudyDo Clinicians Know Which of Their Patients Have Central Venous Catheters?

Vineet Chopra, MD, MSc; Sushant Govindan, MD; Latoya Kuhn, MPH; David Ratz, MS; Randy F. Sweis, MD; Natalie Melin, BA; Rachel Thompson, MD; Aaron Tolan, MD; James Barron, MD; and Sanjay Saint, MD, MPH
[+] Article, Author, and Disclosure Information

From Veterans Affairs Ann Arbor Healthcare System and University of Michigan Health System, Ann Arbor, Michigan; Spectrum Health System, Grand Rapids, Michigan; and Harborview Medical Center, Seattle, Washington.

Acknowledgment: The authors thank Drs. Anneliese Schleyer, Melissa Teply, Shinie Kuo, Prakash Shrestha and Beth Brenner; Ms. Carol Becker; and Ms. Christina Healy for assisting with data collection.

Financial Support: Dr. Chopra was supported by a career development award (1-K08-HS022835-01) from the Agency for Healthcare Research and Quality.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0703.

Reproducible Research Statement:Study protocol: Not available. Statistical code and data set: Available from Dr. Chopra (e-mail, vineetc@umich.edu).

Requests for Single Reprints: Vineet Chopra, MD, MSc, Veterans Affairs Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109; e-mail, vineetc@umich.edu.

Current Author Addresses: Dr. Chopra: Veterans Affairs Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109.

Dr. Govindan: University of Michigan Health System, 1500 East Medical Center Drive, SPC 5376, Ann Arbor, MI 48109.

Ms. Kuhn: Health Services Research and Development, 2800 Plymouth Road, Building 16, 4th Floor, Ann Arbor, MI 48105.

Mr. Ratz: Health Services Research and Development, 2800 Plymouth Road, Building 16, 3rd Floor, Ann Arbor, MI 48109-2800.

Dr. Sweis: University of Chicago, 5841 South Maryland Avenue, MC 2115, Chicago, IL 60637.

Ms. Melin and Dr. Thompson: Harborview Medical Center, Box 359780, Seattle, WA 98104.

Dr. Tolan: Spectrum Health System, Resident Program, 25 Michigan Street NE, Suite 2200, Grand Rapids, MI 49503.

Dr. Barron: Department of Hospital Medicine, Spectrum Health System, 100 Michigan Street NE, Suite A-721, Grand Rapids, MI 49503.

Dr. Saint: Veterans Affairs Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109.

Author Contributions: Conception and design: V. Chopra, S. Govindan, R.F. Sweis, R. Thompson, J. Barron, S. Saint.

Analysis and interpretation of the data: V. Chopra, S. Govindan, L. Kuhn, D. Ratz, R.F. Sweis, N. Melin, R. Thompson, J. Barron, S. Saint.

Drafting of the article: V. Chopra, S. Govindan, L. Kuhn, D. Ratz, R.F. Sweis, J. Barron.

Critical revision of the article for important intellectual content: V. Chopra, R.F. Sweis, R. Thompson, J. Barron, S. Saint.

Final approval of the article: V. Chopra, S. Govindan, L. Kuhn, R.F. Sweis, N. Melin, R. Thompson, J. Barron, S. Saint.

Provision of study materials or patients: V. Chopra, R.F. Sweis, R. Thompson, J. Barron.

Statistical expertise: V. Chopra, D. Ratz.

Obtaining of funding: V. Chopra.

Administrative, technical, or logistic support: V. Chopra, S. Govindan.

Collection and assembly of data: V. Chopra, S. Govindan, L. Kuhn, R.F. Sweis, N. Melin, R. Thompson, J. Barron.


Ann Intern Med. 2014;161(8):562-567. doi:10.7326/M14-0703
Text Size: A A A

Background: Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown.

Objective: To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients.

Design: Multicenter, cross-sectional study.

Setting: 3 academic medical centers in the United States.

Patients: Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings.

Measurements: To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests.

Results: 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n = 209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P = 0.003).

Limitations: Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded.

Conclusion: Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted.

Primary Funding Source: None.

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Clinicians’ awareness of patients having central venous catheters: is it just the catheters?
Posted on November 1, 2014
Aibek E. Mirrakhimov
Saint Joseph Hospital, Chicago
Conflict of Interest: None Declared
I read the recently published study by Chopra et al. with a big interest [1]. The authors surveyed 1881 clinicians (physician extenders, trainees, attending physicians) about the presence of central venous access (femoral, subclavian, internal jugular and peripherally inserted central catheters) among their patients. It is important to note that clinicians were interviewed immediately after rounds, and they were allowed to use patients’ sign- outs and paper written notes, but not the electronic medical records. This study showed that 21.2% of clinicians were not aware of the presence of central venous access in their patients. Critical care physicians and trainees were more frequently aware of the presence of central catheter compared to general internists and hospitalists.
As it was mentioned by the authors, they did not evaluate the potential consequences of such unawareness. However, as pointed by the authors, central venous catheters often stay in place longer that they have to. Furthermore, central lines are not without complications.
What else did we learn from this study? What other questions does it raise? Apparently, it suggests that often our clinical history and physical examination are likely to be cursory. Thus, physical examination should be focused but not limited to the neck, chest, groin and upper extremities area to look for the presence of a central venous access. Another important message is that we as clinicians may not always do proper sign-outs and do not convey all the relevant information. Indeed, good communication between health care providers is an essential tool for better patients’ outcomes. Finally, can we say that we know other parts of our patients’ history and physical exam better than we do with central lines?
In conclusion, this study suggests that clinical history, physical examination and communication between providers all should be greatly stressed and improved.
Do Clinicians Know Which of Their Patients Have Central Venous Catheters?
Posted on November 12, 2014
Steven Z. Kassakian, M.D., Leonard A. Mermel, DO, ScM
SZK - Dept. of Medical Informatics and Clinical Epidemiology, Oregon Health and Sciences University, Portland, OR; LAM -
Conflict of Interest: None Declared
We read with great interest the recent article by Chopra and colleagues (1) examining clinicians’ knowledge regarding the presence of a central venous catheter (CVC), i.e. a triple lumen central venous catheter or peripherally inserted central catheter in their patients. The authors identified hospitalized patients with a CVC and interviewed their treating clinicians after morning rounds, with a single question to determine whether they were aware that their patient had a CVC. During this interview, clinicians were allowed to use whatever notes they had including their sign-out, but not allowed to utilize the electronic medical record (EMR). Not surprisingly, the authors found that for the 209 patients with a CVC, 21% of treating clinicians were unaware of the presence of these catheters.

While we agree with the importance of adherence to guidelines regarding appropriate CVC placement, maintenance and timely removal, we are unsure of the importance of physician's remembering which of their patients has a CVC so long as daily progress notes confirm the presence of a CVC and confirm the continued need for the CVC to safely manage the patient. Regarding this issue, we note that none of the study sites listed in Table 1 has a written protocol to assess CVC or PICC necessity, nor any clinical decision support (CDS) in the EMR regarding the presence of a CVC. Addressing this deficiency is likely more important than addressing clinician's memory of which of their patients has a particular invasive device.

It is worthwhile to note in their methods that at one of the sites, the authors utilized a validated electronic tool to identify the presence of CVC with reported accuracy of 98% but did not themselves examine the patients for the presence of CVC. The irony of utilization of an electronic tool with such high accuracy and potential utility compared with physician recall is not lost on us. We can only assume that use of such CDS tool within the EMR would provide clinical benefit when paired with a prompt addressing whether or not the CVC is required for the safe delivery of patient care.

References
1. Chopra VG, Sushant; Kuhn, Latoya; Ratz, David; Sweis, Randy; Melin, Natalie; Thompson, Rachel; Tolan, Aaron; Barron, James; Saint, Sanjay;. Do Clinicians Know Which of Their Patients Have Central Venous Catheters? A Multicenter Observational Study. Annals of Internal Medicine. 2014;161(8):562-7.

How we solve the problem
Posted on December 12, 2014
Sander Rigter, Peter G. Noordzij, Eric P.A. van Dongen
St. Antoniushospital
Conflict of Interest: None Declared
We have read Chopra and colleagues’ article (1) with great interest. We agree with the authors that in diminishing the risk of central line–associated bloodstream infections (CLABSI) bundle care is of major importance. Besides maximal sterile barrier precaution during insertion, careful selection of insertion site, disinfection with alcoholic chlorhexidin and appropriate hand hygiene (2), a daily check on presence of (local) signs of infection and verification of central line indication are corner stones in reducing complications. It is well known that even the best designed infection prevention program cannot succeed without the commitment of both nursing and medical staff. In our hospital we approximately insert 3,300 central venous catheters (CVC) each year, with a total of 11,000 central-line days and a CLABSI rate of 2.6/1000 days. Because we realize that intravenous access might not have first priority during daily patient visits by the attending clinician, we recently introduced a CVC registration program.
All patients admitted to the hospital are listed in an electronic patient file (EPF). When a CVC is inserted an obligatory electronic form within the EPF is completed. The following items are registered: date of insertion, physician and supervisor who performed the procedure, procedure location (e.g.: OR; ICU, general ward), insertion site, indication (e.g.: TPN, hemodynamic monitoring, hemodialysis), type of catheter and number of lumina. Furthermore, we note whether maximal sterile barrier precautions are applied, if the patient is on therapeutic antibiotics, and if sepsis is present during insertion.
An intensive care nurse driven central line team (CLT) performs daily visits in all patients with a CVC. Patients are checked for signs of local or systemic infection, CVC indication is verified and whether correct CVC care according to hospital protocol (e.g. application of dressing and appropriate hub handling) is maintained. The results are noted in the EPF form and reported to the responsible physician. If necessary, treatment advice is given. The CLT members are available for questions or feedback and provide on-site education. Informing the responsible physician has two major purposes. First, to evaluate CVC necessity and risk of CVC continuation. Second, to increase awareness of CVC presence in a patient. After the CVC is removed the CLT checks the patient’s vital signs and culture results for three more days. Subsequently, CLABSI is diagnosed according to CDC definitions (2).
The CVC registration program is used to investigate hospital CLABSI rate in general and to identify local factors that are associated with CLABSI. Since this program is implemented we are able to perform targeted PDCA cycles to reduce CLABSI on a regular basis (every 3 months). In addition, introduction of this program has led to a greater CVC awareness in our hospital and contributed to continuous improvement in CVC related patient care.

1. Vineet Chopra, MD, MSc; Sushant Govindan, MD; Latoya Kuhn, MPH; David Ratz, MS; Randy F. Sweis, MD et al. Do clinicians know which of their patients have central venous catheters?: a multicenter observational study. Ann Intern Med. 2014;161(8):562-7
2. Naomi P. O'Grady, M.D.1, Mary Alexander, R.N.2, Lillian A. Burns, M.T., M.P.H., C.I.C.3, E. Patchen Dellinger, M.D.4, Jeffery Garland, M.D., S.M.5, Stephen O. Heard, M.D. Guidelines for the Prevention of Intravascular Catheter-Related Infections, Centre of disease control 2011

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