Abstract

Background: Hospitalized patients routinely require a form of vascular access, as do an increasing number of patients receiving care in community settings. Ensuring that the best quality of care is delivered to those requiring vascular access is a difficult task to achieve because multiple care providers initiate, assess, and access these devices. Electronic health records (EHRs) are a tool that may be used to aid clinicians in achieving best practices at the point of care and throughout an organization.

Methods: We describe how EHR technology can be used to support quality improvement initiatives in vascular access practice and its related research and explore the importance and value of embedding vascular access requirements within EHR technology.

Results: EHRs may be a valuable tool for supporting quality improvement efforts in the field of vascular access. Requirements of the clinical specialty such as clinical documentation, reminders and alerts, computerized provider order entry, electronic medication administration, and data extraction can be built into the existing functions of EHRs.

Conclusions: Clinicians practicing in this specialty area should consider working with their clinical informatics and information technology departments to identify opportunities within their organizations to improve how the technology can be leveraged to support vascular access care.

Abstract

Central venous cannulation is routinely done to infuse inotropes, for measuring central venous pressure, for total parenteral infusion, for large-bore venous access, and for infusing chemotherapeutic drugs. Various complications like pneumothorax, hemothorax, chylothorax, malposition, and fracture of catheters are described after central venous cannulation. Malpostioning of a central venous catheter into an anomalously draining left-sided pulmonary vein is a rare complication. We report a case of a patient presenting for carotid body tumor excision in whom the central venous catheter was malpositioned who was found to have a partial anomalous pulmonary venous drainage of the left lung.

Abstract

Background: One of the most common complications of a peripherally inserted central catheter (PICC) is loss of line patency due to platelet adhesion to the device. A new technology called Endexo (Interface Biologics Inc, Toronto, ON, Canada) has been developed that has been shown to reduce platelet adhesion (in bench studies). The purpose of our study was to determine if the use of PICC lines manufactured with Endexo technology would use fewer alteplase doses such that the increased expense of these lines could be offset by a corresponding reduction in alteplase expense.

Methods: The control group received our standard-of-care PICC, the study group received the Endexo PICC, and all patients were followed for a maximum of 60 days postinsertion. Statistical and economic analyses were performed to determine whether a significant reduction in alteplase use was observed, and whether the increased cost of the new novel PICCs could be offset by a reduction in alteplase-related expense.

Results: Our study enrolled patients who underwent 157 PICC insertions in the control group and 145 PICC insertions in the study group. We found no statistical difference in average alteplase doses per line, number of PICCs requiring an alteplase dose, or time to first dose of alteplase between study groups. An economic analysis revealed that at our institution, adopting PICCs with Endexo technology would result in increased expenses.

Conclusions: In our patient population we were unable to observe a reduction in alteplase use to offset the increased costs of this novel PICC when catheters were followed for a maximum of 60 days postinsertion.

Abstract

Objective: The purpose of this institutional review board-approved, single-blinded, randomized controlled trial was to evaluate the effectiveness of bedside peripherally inserted central catheter (PICC) tip placement using a nonproprietary electocardiogram (EKG) machine and wide-mouth EKG clip connected to the right arm lead and PICC guide wire. The hospital site in this study was an 800-bed community, nonacademic, Magnet hospital in the southeastern United States.

Methods: All patients who provided consent and were eligible for bedside PICC insertion were randomly assigned to either standard PICC insertion or standard PICC insertion plus EKG guidance. Placement was identified by observing for P wave changes, which indicated PICC tip location in relationship to the sinoatrial node in the superior vena cava. After the PICC lines were placed, 2 radiologists blinded to treatment assignment independently reviewed confirmatory chest radiographs. De-identified data were collected and analyzed.

Results: One hundred eighty-seven patients participated in this study. Of all patients, 94.6% had a baseline rhythm with a discernable P wave. The time to insert the PICC while using EKG guidance increased by a mean difference of 9 minutes (P = .001). The time to notification of the floor nurse that the PICC was read by a radiologist and ready to use for infusions was not significant between groups. In the control group, 91.8% of PICC lines were placed to completion at the bedside vs 90.2% in the experimental group (P = .710). PICCs placed with EKG guidance were successfully placed with the first attempt or 1 pass (89%; n = 91) vs PICCs placed without EKG guidance (75%; n = 63; P = .01). Of the control group, 40% (n = 34) and of the experimental group, 48% (n = 49) had PICC lines placed within 1.5 cm of the sinoatrial junction. Of the control group, 53% (n = 45) and of the experimental group, 65% (n = 66) had PICC lines placed within 1.5 cm of the sinoatrial junction to 3.0 cm above the sinoatrial junction (P = .10). Of the control group, 64.8% (n = 55) and of the experimental group, 82.2% (n = 84) had PICC lines placed within 1.5 cm of the sinoatrial junction to 6.0 cm above the sinoatrial junction (P =.3). Of the control group, 7.1% (n = 6) and of the experimental group, 2.9% (n = 3) had PICC lines placed 6.1 cm or more above the sinoatrial junction. Of the control group, 18.8% (n = 16) and of the experimental group, 8.8% (n = 9) had PICC lines placed too deep in the superior vena cava and below 1.6 cm (P < .05). PICCs inserted with or without EKG guidance statistically had the same amount of chest radiograph images performed (P =.083). Three groups reviewed the chest radiographs to determine the PICC tip location and they agreed to the location 82% of the time and a significant positive correlation between all 3 groups existed. The PICC Team subjectively identified 22 patients as obese. No statistical significance was realized among patients not identified as obese vs those identified as obese.

Conclusions: The data revealed that the control and experimental groups were equally distributed for baseline demographic characteristics such as sex and age. Importantly, it was determined that 94% of participants had a discernable P wave and were candidates for the use of EKG guidance. The time to insert a PICC line at bedside with the use of EKG guidance increased the procedure time by a mean of 9 minutes; however, the ultimate infiuence on patient care resulted in a savings of 67 minutes after factoring in an average of 76 minutes for radiograph confirmation. Complications and the need to reposition PICC lines were not found to be significant or vastly different or improved with or without the use of EKG guidance. PICC lines placed with the use of EKG guidance were significantly unlikely to be repositioned. Lastly, it was found that obesity did not play any particular role. Based on these findings, the facility determined that EKG guidance is effective and its use was implemented for all bedside PICC placements in which a P wave was discernable.