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Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound

A Survey of Early Adopters

Ablordeppey, Enyo A.*,†; Drewry, Anne M.*; Theodoro, Daniel L.; Tian, LinLin; Fuller, Brian M.*,†; Griffey, Richard T.

doi: 10.1097/SHK.0000000000001218
Clinical Science Aspects
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Purpose: Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography.

Methods: We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS.

Results: Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion “most of the time” or “always,” none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion.

Conclusions: Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.

*Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, Saint Louis, Missouri

Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, Missouri

Address reprint requests to Enyo A. Ablordeppey, MD, MPH, 660 South Euclid Avenue CB 8072, St Louis, MO 63110 E-mail: ablordeppeye@wustl.edu

Received 22 May, 2018

Revised 6 June, 2018

Accepted 2 July, 2018

EAA was supported by Washington University School of Medicine Faculty grant. Drs EAA, LXT, and DLT conducted this research with resources from the Washington University Emergency Care Research Core, which receives funding from the Foundation for Barnes-Jewish Hospital. AMD was supported by the Division of Clinical and Translational Research of the Department of Anesthesiology at Washington University School of Medicine, and the Washington University Institute of Clinical and Translational Sciences grants UL1 TR000448 and KL2 TR000450 from the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH). BMF was supported by a KL2 TR000450 from the National Center for Advancing Translational Sciences of the NIH. RTG was supported by grant 1 R18 HS025052-01 from the Agency for Healthcare Research and Quality, grant P30DK092950 from the NIH/National Institute of Diabetes and Digestive and Kidney Disorders, Washington University Center for Diabetes Translation Research, and grant 3767 from the Barnes Jewish Hospital Foundation. The authors report no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.shockjournal.com).

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INTRODUCTION

Point-of-care ultrasonography (POCUS) is a rapidly developing discipline incorporated by multiple medical specialties, including Emergency Medicine and Critical Care Medicine (1). POCUS allows for rapid, bedside assessment of critically ill patients (2) and improves procedural success and safety during central venous catheter (CVC) placement, which is one of the most common procedures performed in the management of critically ill patients (3, 4). Risks during CVC insertion (5, 6) include iatrogenic pneumothorax (PTX) (up to 3.3%) and catheter malposition (up to 14%) during internal jugular vein and subclavian vein insertions (7, 8). CVC malposition may be associated with inaccuracies in hemodynamic measurements, venous thrombosis, and delays in treatment (5, 6), while PTX often requires additional monitoring and possible procedural interventions.

For over 50 years, CXR has been the standard method to evaluate CVC position and identify potential complications such as a PTX (9, 10). Mounting evidence suggests that POCUS enhances rapid decision-making, assists physicians’ diagnostic capabilities, and improves patient safety during procedures. In addition, more literature suggests that a post-procedure CXR is unnecessary when ultrasound is used to confirm catheter position and exclude pneumothorax (11, 12). In fact, data demonstrate that ultrasound provides equivalent diagnostic findings to CXR in confirming the catheter location and in excluding mechanical complications like PTX but does so faster. Finally, POCUS has advantages over chest radiography including avoidance of ionizing radiation exposure, optimized resource utilization, and decreased time to diagnosis (13). Immediate confirmation of CVC positioning allows for earlier clinical management that could affect patient outcomes, particularly in critically ill patients (14–16). A recent meta-analysis found that POCUS detected all pneumothoraces and most catheter malpositions following CVC placement while much faster than chest radiography (17).

Clinicians currently recognize the benefit of ultrasound for procedural guidance. POCUS for CVC placement is now recognized as a best practice that is endorsed by the Agency for Healthcare Research and Quality, the National Quality Forum, and is reflected in national quality measures used for public reporting and reimbursement (18, 19). In a recent national survey, nearly all physicians (99%) who insert internal jugular CVCs daily reported using ultrasound guidance (20). However, despite nearly a decade of data demonstrating efficacy of POCUS for confirmation of CVC position and exclusion of pneumothoraces (17, 21), the extent to which POCUS has been adopted for these purposes is unknown. We hypothesize that few in the medical community are likely aware of these data and even among those who are aware, CXR continues to be the routine modality used. The primary purpose of this study was to determine current practices of CVC position confirmation and PTX exclusion by POCUS alone after CVC placement as well as to determine possible barriers to using ultrasound alone for this purpose. To provide a “best case scenario” in estimating the wider use of POCUS, we surveyed emergency and critical care physicians across the United States most likely to be experienced in the use of POCUS and aware of the literature on its use for the purpose of CVC position confirmation and PTX exclusion.

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PATIENTS AND METHODS

Subjects

Using an electronic mailing list from an ultrasound-focused critical care medicine society of US practicing physicians and a list of Emergency Medicine and Critical Care Medicine alumni physicians from our own training programs, we invited a total of 200 post-training clinicians to participate in an online survey (Qualtrics, Provo, Utah). No compensation was offered for survey completion. For implementation of proven survey methodology, we employed a modified Dillman technique, which has demonstrated higher rates of survey return (initial invitation with a web link to the survey, followed by up to three weekly email reminders for non-responders) (22). All survey responses were anonymous. Our Institutional Review Board declared this study exempt from formal review and written informed consent because of the anonymous and voluntary nature of the survey.

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Survey development

The study team consisted of emergency and critical care physicians with expertise in POCUS and survey design. We developed a 10-item questionnaire based on existing literature and knowledge of current local practices. The questionnaire consisted of multiple-choice questions assessing the use of ultrasound guidance for CVC insertion and postinsertion practices. The questionnaire consisted of specific questions regarding demographics, previous POCUS training, number of CVC insertions performed, current use of ultrasound guidance for CVC insertion and position confirmation, and perceived barriers to ultrasound use for CVC position confirmation and PTX evaluation. The survey was independently pilot-tested on 10 different Emergency Medicine and/or Critical Care Medicine physicians who provided feedback on the relevance, wording, validity, and clarity of each survey item, in addition to the estimated time required for survey completion. POCUS is used interchangeably with “ultrasound.” The resulting modified survey is provided in Supplemental Digital Content File 1 (http://links.lww.com/SHK/A783).

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Statistical methods

The raw survey response data were digitally exported from Qualtrics. All statistical analyses were performed with R Statistical Software (Foundation for Statistical Computing, Vienna, Austria) version 3.4.0 (23). Descriptive data included proportions and 95% confidence intervals (CIs) estimated using a percentile bootstrap method (24). Generalized Cochran–Mantel–Haenszel tests were used to test the association of ordinal variables (25, 26) such as duration of medical practice.

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RESULTS

A total of 200 participants were invited to participate in the survey with a complete survey response rate of 68% (136/200). Survey participant characteristics are presented in Table 1. Fifty-two percent of respondents have been in practice for 5 years or less. As their primary practice setting, 71% of respondents work in academics and 88% reported prior structured ultrasound training.

Table 1

Table 1

Current estimates of the frequency of CVC insertions after medical training are reported in Table 2. Thirty-eight percent of respondents reported placing or supervising greater than 400 supra-diaphragmatic CVCs (internal jugular and subclavian veins only). Eighty-five percent of providers reported using ultrasound routinely during supra-diaphragmatic CVC insertion (internal jugular vein and subclavian vein). CVC position confirmation practices for routine confirmation are shown in Table 3, with 49% of respondents reporting the use of both ultrasound and chest radiography together while 51% report using chest radiography only for routine CVC position confirmation. Notably, none of the survey respondents reported using POCUS alone as a routine method of confirming catheter positioning and only 1% reported using POCUS alone for PTX exclusion after CVC insertion.

Table 2

Table 2

Table 3

Table 3

The probability of providers using POCUS as the sole method to confirm CVC position and PTX evaluation without chest radiography are shown in Table 4. Physicians with more experience were more likely to adopt ultrasound as the sole method to confirm CVC position as compared with physicians with less experience (P = 0.04). No significant difference exists between physicians of differing training duration in using POCUS to exclude PTX (P = 0.07).

Table 4

Table 4

The list of perceived factors affecting current use of ultrasound guided CVC position confirmation and PTX exclusion are presented in Table 5 and Supplemental Digital Content 2 (http://links.lww.com/SHK/A784). The most commonly reported factors preventing use of ultrasound alone during CVC position confirmation and PTX exclusion were “My hospital has a policy or protocol requiring radiography after line placement,” “Political forces in my hospital would oppose this, as I would be in the minority of performing the ultrasound protocol,” and “I do not feel adequately comfortable with my ultrasound skills to make this call” which were reported by 17%, 16%, and 14% of respondents respectively. Additional barriers included lack of awareness that ultrasound could be used in this capacity (4%), it is more convenient to obtain a chest radiograph (7%), and inertia “I don’t think of it or it is just hard to change behavior and break habits” (11%).

Table 5

Table 5

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DISCUSSION

To our knowledge, this is the first study that has evaluated CVC confirmation practices by POCUS alone among Critical Care Medicine and Emergency Medicine Physicians, two groups historically well versed in the CVC procedure and in the use of POCUS. In this survey, most respondents report routinely using POCUS for CVC insertion. However, even among those who received structured ultrasound training, only half routinely use POCUS with chest radiography for CVC position and PTX exclusion and only 1% use POCUS alone to exclude a PTX. None use ultrasound alone for CVC position confirmation. In our study, lack of comfort with POCUS for this indication was the third most commonly listed barrier to implementation of POCUS for CVC position confirmation and PTX exclusion. Limited incorporation of POCUS in nonvascular applications in residency and fellowship training programs may result in lack of comfort in using ultrasound alone for these purposes after training (27). POCUS alone protocol for CVC position confirmation and PTX exclusion typically includes cardiac and lung ultrasound in addition to vascular ultrasound.

As noted, advantages to use of POCUS alone for confirmation of CVC placement in critically ill patients include efficiency (time to confirmation), reduction in ionizing radiation exposure, relocation of hospital equipment resources, and cost. A recent meta-analysis showed that ultrasound use in CVC position confirmation was feasible (98% adequate visualization), fast (reduced mean CVC confirmation time by 58.3 min compared with chest radiography), and accurate (could detect four of five venous catheter malpositions) (17). The pooled sensitivity and specificity of POCUS-detected catheter malposition was 0.82 (95% CI 0.77, 0.86) and 0.98 (95% CI 0.97, 0.99), respectively, and the sensitivity and specificity of ultrasound for PTX detection were nearly 100% among the 15 studies (1553 CVC placements) included in the meta-analysis. Since that publication, several additional studies have demonstrated similar results with even better sensitivity of POCUS to detect catheter malposition (21, 28). These observational studies suggest that ultrasound is a reasonable first screening test to confirm CVC position and PTX exclusion based on its efficiency and diagnostic noninferiority to chest radiography. In addition, a recent randomized controlled study demonstrated a reduction in the time from CVC insertion to first use with ultrasound-only CVC position confirmation and PTX exclusion compared with routine post-procedure chest radiography as well as a statistically significant reduction in chest radiograph utilization (29). While data supporting use of POCUS for CVC position confirmation and PTX exclusion as a reasonable first screen alternative to chest radiography is compelling, our study suggests that this practice does not yet enjoy widespread adoption. This study sets an important foundation for why changes in clinical practice are warranted.

Adoption of POCUS for CVC insertion was aided by national efforts to disseminate evidence, national societal guidelines, and quality measures. Though today POCUS for CVC insertion is considered standard of care, initially this practice had a slow rate of adoption similar to POCUS alone for CVC position confirmation and PTX exclusion. Even after many studies demonstrated improvements in CVC associated complications, time to CVC insertion, and successful first cannulation attempt, use of ultrasound for CVC insertion remained limited (3). Qualitative studies analyzing the clinical practice of CVC insertion and barriers to implementation of POCUS during CVC insertion, like this study, were influential in developing strategies for improved adoption (30, 31). Ultimately, the Agency for Healthcare Research and Quality and other national organizations strongly recommended ultrasound guidance for all central venous cannulation to improve patient care and patient safety (31, 32). Recent data suggest that POCUS guidance for CVC insertion is still growing and is now approximately 83% to 85% compared with 34% to 44% in 2012 (18).

To achieve the widespread adoption of POCUS alone for CVC position confirmation and PTX exclusion, similar dissemination and implementation efforts will be needed. The first step is to assess the current practices and determine the barriers against widespread adoption. Of the 10 potential barriers offered in the survey, respondents cited hospital policy or politics, standard of care, and lack of comfort as the most common reasons for not using ultrasound alone as opposed to chest radiography for CVC position confirmation and PTX exclusion. It is interesting to note that respondents who reported confidence using ultrasound for CVC insertion reported lack of confidence in using POCUS for CVC confirmation. Studies show that physicians can perform focused ultrasound examinations capably after a short intensive training period and can demonstrate improved comfort after training (33). Ultrasound guided CVC confirmation protocols can be easily taught to physicians and as knowledge translation occurs, it should be associated with increased comfort, thus gaining widespread implementation, and eventually become part of standard practice. Perceived convenience of chest radiography as compared with ultrasound was not a strongly reported barrier. This may be because the respondents are already familiar with POCUS and do not perceive this as an inconvenience.

Notably, only 4% reported that they did not know that ultrasound could be used in the manner, suggesting that knowledge dissemination is not the major barrier in this population mostly likely to use POCUS. We hypothesize that three crucial elements to attaining widespread acceptance of POCUS by the clinician include: ultrasound knowledge and skill competence, comfort, and confidence (34). Understanding these processes may be useful in early adoption of ultrasound-guided CVC position confirmation and PTX exclusion. In addition, clinicians should investigate whether their hospitals indeed have policies related to CVC position confirmation and whether these specify confirmation with chest radiography, and if so, hospitals and national specialty groups should consider re-evaluating these guidelines and policies. More work is needed to identify and understand the factors that facilitate or hinder change in this clinical practice, particularly in this target group who represent early adopters of POCUS. This study and future work will help inform selection of theoretical frameworks for implementation strategies that will improve adoption of these evidence-based clinical practice recommendations.

Our study has limitations, the survey is a small sample of practicing Emergency Medicine physicians and/or Critical Care Medicine physicians most likely to use POCUS for CVC confirmation and who represent a population of potential early adopters to POCUS for this indication. It is possible that physicians who use ultrasound guidance during CVC placement preferentially responded to the survey, which may have skewed our results but in light of our results and prior findings, we think this is unlikely. We attempted to solicit responses from a broad geographical distribution in the United States, but the survey was not designed to be nationally representative. Though these are self-reported data, we have no reason to believe that responses are inaccurate or include systematically biases. Our survey was only distributed among participants in the United States. It is possible that the practice patterns regarding CVC position confirmation and PTX exclusion may be different in other countries, where austere conditions could conceivably make use of POCUS even more compelling where available. Finally, though we did perform pilot testing, we were unable to present psychometric data for this survey instrument. Our results reflect attitudes and self-reported behaviors rather than observed behaviors and are subject to recall bias. However, surveys were anonymous to encourage accurate responses and our response rate is similar to published expectations on survey response rates (35).

Emerging evidence suggests that a post-procedure CXR is unnecessary when ultrasound is used to confirm catheter position and exclude pneumothorax. In fact, data demonstrate that ultrasound provides equivalent diagnostic findings to CXR in confirming the catheter location and in excluding PTX but does so faster. Yet few in the medical community are likely aware of the strength of this cumulative data and even among those who are aware, CXR continues to be the routine modality used. This study highlights the current clinical practices and attitudes toward ultrasound-guided CVC position confirmation and PTX exclusion among providers (emergency medicine and critical care medicine) most likely to use POCUS for these purposes. Our data suggests that the translation of evidence to clinical practice in this area by emergency medicine and critical care medicine physicians is limited, and we have identified some basic perceived barriers to implementation. This is an important determinant as efforts to address barriers at the provider and system levels are needed to increase the adoption of POCUS only for CVC position confirmation and PTX exclusion. A more comprehensive national survey, and/ or use of qualitative research methods, might be useful in identifying factors that could influence the implementation of ultrasound-guided CVC position confirmation and PTX exclusion protocols among a general pool of providers. Future work might also focus on cost-effectiveness and hospital resource re-allocation implications of ultrasound versus chest radiography after CVC insertion.

Despite literature demonstrating its efficacy, use of ultrasound alone for CVC position confirmation and PTX evaluation, even among experienced providers with training in POCUS, is very low. This study confirms the need for strategic interventions to improve the dissemination and adoption of POCUS for CVC catheter position confirmation and PTX exclusion. Understanding the reasons for lack of adoption of ultrasound is critical to effective dissemination and implementation strategies. Participants identified several barriers to this practice, suggesting a number of potential areas for development in the quest to change clinical practice.

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Acknowledgment

The authors thank Richard Hotchkiss, Professor of Anesthesiology, Medicine, and Surgery at Washington University School of Medicine for reviewing this manuscript and offering suggestions.

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Keywords:

Central line; pneumothorax; survey; ultrasound

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