Improving Compliance with Central Venous Catheter (CVC) Insertion Best Practices in the Emergency Department (ED)

Background: Compliance with central line bundles can reduce CVC-associated infection rates. Although CVC insertions are common in the ED, little attention has been paid to practice improvement in this area.

Objective: To improve compliance with best practices for CVC insertion in the ED.

Methods: A prospective observational cohort study was performed between Nov 2006 and Jan 2009 in two EDs of a tertiary care referral center. Observations were conducted by nurses assisting with the procedure using a standardized audit tool. Data were collected for each new site attempted and each new operator. Following 1 year of baseline data collection, physicians were trained using a web-based simulation. Nurses were empowered to identify a breach and advise the physician so that corrective action could be taken. Compliance data were collected post-intervention to measure the effectiveness of the intervention.
Results: 98 central line insertions on 85 patients were observed. CVC insertions were performed by staff physicians (26%) or residents (74%) from Emergency Medicine (37%), Intensive Care (33%), Medicine (10%), or other services (20%). Most insertions were considered emergent (44%) or urgent (54%). Post-intervention, compliance with all recommended infection control practices increased significantly from 29% to 69% (OR=5.6; CI=2.1-14.4). A significant improvement in compliance was seen in residents (75% vs 29%; p<0.001) but not staff physicians (57% vs 30%; p=0.1). There was no relationship between compliance and the urgency of the procedure, service, time of day or day of the week.

Compliance with Infection Control Measures During CVC Insertion in the ED

Measure	% Compliance Pre-Intervetion	% Compliance Post-Intervention	Odds Ratio	95% Confidence Interval	P-value
Operator hand hygiene	86.4	85.9	1.0	0.2-4.5	NS
Operator use of barrier equipment	65.6	90.8	5.1	1.5-18.2	0.002
Assistant hand hygiene	80.0	93.3	3.5	0.6-19.4	NS
Assistant use of barrier equipment	42.3	87.3	9.4	2.7-33.5	<0.001
Proper skin disinfection	90.6	98.5	6.6	0.6-172.7	NS
Use of sterile drape	75.0	92.2	3.9	1.0-15.7	NS
Maintenance of sterile field	84.3	98.4	11.7	1.2-276.9	0.01

Conclusions: A significant improvement in compliance with infection control measures during CVC insertion can be achieved in the ED despite the urgency of the procedure. The greatest impact was seen among resident physicians and in the use of proper barrier equipment. These findings can have an important impact on preventing CVC-associated bloodstream infections and supporting patient safety initiatives.