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).
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.
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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