Case: Central Line Bundle: Improving Patient Safety
Case: Central Line Bundle: Improving Patient Safety
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Video case study covering the 6-point central line bundle.
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<p begin="00:00:15.573" end="00:00:17.038" style="s2">- [Voiceover] In this<br />Soundbytes module, we'll discuss</p>
<p begin="00:00:17.038" end="00:00:19.563" style="s2">how we can improve patient<br />safety through a concept</p>
<p begin="00:00:19.563" end="00:00:22.099" style="s2">known as a central line bundle.</p>
<p begin="00:00:22.099" end="00:00:24.924" style="s2">Now the central line bundle<br />is a six step checklist</p>
<p begin="00:00:24.924" end="00:00:28.016" style="s2">of initiatives that can<br />decrease both the infectious,</p>
<p begin="00:00:28.016" end="00:00:32.183" style="s2">and mechanical complications<br />of central line placement.</p>
<p begin="00:00:33.620" end="00:00:35.340" style="s2">Let's begin this module<br />by going over some of the</p>
<p begin="00:00:35.340" end="00:00:39.054" style="s2">potential patient benefits<br />of central venous access.</p>
<p begin="00:00:39.054" end="00:00:41.940" style="s2">Central venous access allows more secure</p>
<p begin="00:00:41.940" end="00:00:44.462" style="s2">vascular access in our sickest patients,</p>
<p begin="00:00:44.462" end="00:00:46.324" style="s2">and gives us the ability to deliver</p>
<p begin="00:00:46.324" end="00:00:49.407" style="s2">high flow infusions in these patients.</p>
<p begin="00:00:49.407" end="00:00:52.787" style="s2">Central venous access is also<br />a safer administration route</p>
<p begin="00:00:52.787" end="00:00:56.248" style="s2">of vasopressors as opposed<br />to the peripheral route.</p>
<p begin="00:00:56.248" end="00:00:59.137" style="s2">A central line allows for<br />better hemodynamic monitoring</p>
<p begin="00:00:59.137" end="00:01:01.537" style="s2">of our patients, allowing you to monitor</p>
<p begin="00:01:01.537" end="00:01:04.305" style="s2">central venous pressure, or CVP, and also</p>
<p begin="00:01:04.305" end="00:01:06.888" style="s2">mixed venous oxygen saturation.</p>
<p begin="00:01:07.895" end="00:01:10.166" style="s2">However there are some<br />serious patient risks involved</p>
<p begin="00:01:10.166" end="00:01:12.559" style="s2">with placement of a<br />central venous catheter.</p>
<p begin="00:01:12.559" end="00:01:15.366" style="s2">The two main groups of<br />complications are the mechanical,</p>
<p begin="00:01:15.366" end="00:01:17.102" style="s2">and the infectious.</p>
<p begin="00:01:17.102" end="00:01:19.751" style="s2">Those included under<br />mechanical complications are</p>
<p begin="00:01:19.751" end="00:01:23.518" style="s2">pneumothorax formation,<br />hemothorax formation,</p>
<p begin="00:01:23.518" end="00:01:28.481" style="s2">and inadvertent arterial<br />puncture with hematoma formation.</p>
<p begin="00:01:28.481" end="00:01:31.639" style="s2">The second main category are<br />the infectious complications</p>
<p begin="00:01:31.639" end="00:01:33.854" style="s2">and central associated<br />bloodstream infections</p>
<p begin="00:01:33.854" end="00:01:36.144" style="s2">are increasingly recognized<br />cause of increased</p>
<p begin="00:01:36.144" end="00:01:39.972" style="s2">morbidity and mortality<br />in our sickest patients.</p>
<p begin="00:01:39.972" end="00:01:41.812" style="s2">Because of these<br />recognized complications of</p>
<p begin="00:01:41.812" end="00:01:45.197" style="s2">central line placement, bedside<br />ultrasound has stepped up</p>
<p begin="00:01:45.197" end="00:01:47.980" style="s2">to help us lower the complication rate.</p>
<p begin="00:01:47.980" end="00:01:50.084" style="s2">Bedside ultrasound dramatically decreases</p>
<p begin="00:01:50.084" end="00:01:53.124" style="s2">the mechanical complications<br />of central line placement,</p>
<p begin="00:01:53.124" end="00:01:55.508" style="s2">allowing real time guidance<br />of the cannulating needle</p>
<p begin="00:01:55.508" end="00:01:57.484" style="s2">into the central vein.</p>
<p begin="00:01:57.484" end="00:02:00.440" style="s2">Bedside ultrasound is now recommended by</p>
<p begin="00:02:00.440" end="00:02:03.420" style="s2">governmental agencies and<br />multiple medical societies</p>
<p begin="00:02:03.420" end="00:02:06.994" style="s2">as an aid in placement of central lines.</p>
<p begin="00:02:06.994" end="00:02:09.219" style="s2">And over recent years there's<br />been increasing momentum</p>
<p begin="00:02:09.219" end="00:02:10.597" style="s2">in initiatives to decrease</p>
<p begin="00:02:10.597" end="00:02:13.373" style="s2">central line associated infections.</p>
<p begin="00:02:13.373" end="00:02:17.753" style="s2">Two major initiatives were<br />the IHI 100,000 Lives Campaign</p>
<p begin="00:02:17.753" end="00:02:20.514" style="s2">which came out in 2005,<br />with the aim to improve</p>
<p begin="00:02:20.514" end="00:02:23.584" style="s2">patient safety in all USA hospitals.</p>
<p begin="00:02:23.584" end="00:02:26.969" style="s2">Also in 2006, the Joint Commissions, JCAHO</p>
<p begin="00:02:26.969" end="00:02:29.536" style="s2">came out with the Six<br />National Safety Goals,</p>
<p begin="00:02:29.536" end="00:02:31.529" style="s2">also with the aim of reducing risk of</p>
<p begin="00:02:31.529" end="00:02:34.265" style="s2">health care associated infections.</p>
<p begin="00:02:34.265" end="00:02:36.849" style="s2">The Institute for Health<br />Care Improvement, or IHI</p>
<p begin="00:02:36.849" end="00:02:39.639" style="s2">recommendations for central<br />venous access include</p>
<p begin="00:02:39.639" end="00:02:41.590" style="s2">five major initiatives.</p>
<p begin="00:02:41.590" end="00:02:44.797" style="s2">The first is increasing<br />attention to hand hygiene.</p>
<p begin="00:02:44.797" end="00:02:48.086" style="s2">Number two, adequate skin antisepsis,</p>
<p begin="00:02:48.086" end="00:02:51.190" style="s2">number three, maximal barrier precautions,</p>
<p begin="00:02:51.190" end="00:02:54.272" style="s2">number four, catheter site selection,</p>
<p begin="00:02:54.272" end="00:02:56.694" style="s2">and number five, daily review of the need</p>
<p begin="00:02:56.694" end="00:02:58.774" style="s2">for a central line.</p>
<p begin="00:02:58.774" end="00:03:01.838" style="s2">If one adds ultrasound<br />guidance of line placement</p>
<p begin="00:03:01.838" end="00:03:05.605" style="s2">to the five point IHI<br />recommendations of hand hygiene,</p>
<p begin="00:03:05.605" end="00:03:08.722" style="s2">skin antisepsis, maximal<br />barrier precautions,</p>
<p begin="00:03:08.722" end="00:03:11.463" style="s2">catheter site selection,<br />and daily review of the need</p>
<p begin="00:03:11.463" end="00:03:14.062" style="s2">for central line, one<br />gets to the central line</p>
<p begin="00:03:14.062" end="00:03:16.622" style="s2">six point bundle, the current standard</p>
<p begin="00:03:16.622" end="00:03:20.865" style="s2">for decreasing complications<br />of central line placement.</p>
<p begin="00:03:20.865" end="00:03:22.600" style="s2">Before performing central venous access,</p>
<p begin="00:03:22.600" end="00:03:25.587" style="s2">it's mandatory to perform a<br />checklist prior to the procedure</p>
<p begin="00:03:25.587" end="00:03:27.865" style="s2">to decrease the complication rate.</p>
<p begin="00:03:27.865" end="00:03:29.664" style="s2">The first thing one should do is to review</p>
<p begin="00:03:29.664" end="00:03:32.730" style="s2">the patient charts for those<br />increased procedural risks</p>
<p begin="00:03:32.730" end="00:03:35.553" style="s2">to our patients, such as coagulopathy,</p>
<p begin="00:03:35.553" end="00:03:38.520" style="s2">thrombocytopenia, the presence of a DVT</p>
<p begin="00:03:38.520" end="00:03:41.409" style="s2">within the upper extremity<br />or lower extremity veins,</p>
<p begin="00:03:41.409" end="00:03:43.649" style="s2">or a known latex allergy.</p>
<p begin="00:03:43.649" end="00:03:46.368" style="s2">One should obtain informed<br />consent from our patients,</p>
<p begin="00:03:46.368" end="00:03:49.416" style="s2">also performing a prescan<br />ultrasound to look for a clot</p>
<p begin="00:03:49.416" end="00:03:51.404" style="s2">in the targeted veins.</p>
<p begin="00:03:51.404" end="00:03:54.008" style="s2">Last but not least, it's<br />optimal and mandatory</p>
<p begin="00:03:54.008" end="00:03:56.136" style="s2">to perform a time out procedure together</p>
<p begin="00:03:56.136" end="00:03:57.988" style="s2">with the nursing staff.</p>
<p begin="00:03:57.988" end="00:04:00.432" style="s2">Going through the IHI<br />guidelines for decreasing</p>
<p begin="00:04:00.432" end="00:04:02.904" style="s2">the complication rate for<br />central venous access,</p>
<p begin="00:04:02.904" end="00:04:05.129" style="s2">the first step is to wash<br />your hands thoroughly</p>
<p begin="00:04:05.129" end="00:04:06.640" style="s2">prior to the procedure.</p>
<p begin="00:04:06.640" end="00:04:09.120" style="s2">As an alternative, one can<br />consider application of</p>
<p begin="00:04:09.120" end="00:04:12.273" style="s2">alcohol based, waterless<br />hand cleansers which offer</p>
<p begin="00:04:12.273" end="00:04:16.715" style="s2">additional disinfection benefit<br />over conventional washing.</p>
<p begin="00:04:16.715" end="00:04:19.092" style="s2">The second step for decreasing<br />the complication rate</p>
<p begin="00:04:19.092" end="00:04:21.403" style="s2">of central venous access,<br />is adequate attention</p>
<p begin="00:04:21.403" end="00:04:23.170" style="s2">to skin antisepsis.</p>
<p begin="00:04:23.170" end="00:04:26.474" style="s2">For this initiative, Chlorhexidine<br />is going to be optimal.</p>
<p begin="00:04:26.474" end="00:04:28.693" style="s2">Chlorhexidine offers<br />benefits over traditional</p>
<p begin="00:04:28.693" end="00:04:31.989" style="s2">Povidine-iodine with<br />regard to skin antisepsis,</p>
<p begin="00:04:31.989" end="00:04:34.132" style="s2">and it's best to scrub<br />the Chlorhexidine sponge</p>
<p begin="00:04:34.132" end="00:04:37.246" style="s2">vigorously across your<br />patient's skin for 20 seconds,</p>
<p begin="00:04:37.246" end="00:04:40.067" style="s2">applying three Chlorhexidine<br />scrubs sequentially</p>
<p begin="00:04:40.067" end="00:04:43.564" style="s2">to a wide field area<br />over the patient's skin.</p>
<p begin="00:04:43.564" end="00:04:45.361" style="s2">The third step is adequate attention to</p>
<p begin="00:04:45.361" end="00:04:47.329" style="s2">maximal barrier precautions during the</p>
<p begin="00:04:47.329" end="00:04:49.625" style="s2">central venous placement procedure.</p>
<p begin="00:04:49.625" end="00:04:52.681" style="s2">The operator and all<br />assistants should wear a cap,</p>
<p begin="00:04:52.681" end="00:04:54.939" style="s2">mask, sterile gown and sterile gloves</p>
<p begin="00:04:54.939" end="00:04:56.593" style="s2">throughout the procedure.</p>
<p begin="00:04:56.593" end="00:04:58.617" style="s2">It's important to place<br />a wide field barrier</p>
<p begin="00:04:58.617" end="00:05:00.321" style="s2">over the patient during the procedure</p>
<p begin="00:05:00.321" end="00:05:03.129" style="s2">to decrease the infectious<br />risk to our patient.</p>
<p begin="00:05:03.129" end="00:05:05.298" style="s2">The patient should be<br />covered from head to toe</p>
<p begin="00:05:05.298" end="00:05:08.113" style="s2">with this wide field barrier,<br />with only a small opening</p>
<p begin="00:05:08.113" end="00:05:11.075" style="s2">for the insertion site<br />of the central line.</p>
<p begin="00:05:11.075" end="00:05:13.361" style="s2">The fourth main step<br />within the IHI guidelines,</p>
<p begin="00:05:13.361" end="00:05:15.346" style="s2">is adequate attention to site selection</p>
<p begin="00:05:15.346" end="00:05:17.738" style="s2">for placement of a<br />central venous catheter.</p>
<p begin="00:05:17.738" end="00:05:20.146" style="s2">In general, high lines are preferred.</p>
<p begin="00:05:20.146" end="00:05:22.591" style="s2">The internal jugular<br />vein and subclavian vein</p>
<p begin="00:05:22.591" end="00:05:24.443" style="s2">are associated with a decreased risk of</p>
<p begin="00:05:24.443" end="00:05:27.477" style="s2">infectious complications to our patients.</p>
<p begin="00:05:27.477" end="00:05:29.867" style="s2">In general, low lines are less preferred,</p>
<p begin="00:05:29.867" end="00:05:32.292" style="s2">as placement of a catheter<br />into the femoral vein</p>
<p begin="00:05:32.292" end="00:05:34.555" style="s2">is associated with<br />higher risk of infection,</p>
<p begin="00:05:34.555" end="00:05:38.603" style="s2">and also a higher risk<br />of DVT in our patients.</p>
<p begin="00:05:38.603" end="00:05:40.371" style="s2">Critical actions following placement of a</p>
<p begin="00:05:40.371" end="00:05:43.611" style="s2">central venous catheter<br />include using sterile technique</p>
<p begin="00:05:43.611" end="00:05:46.253" style="s2">to flush all lines of the<br />catheter, and then putting</p>
<p begin="00:05:46.253" end="00:05:49.035" style="s2">sterile catheter caps on all lumens.</p>
<p begin="00:05:49.035" end="00:05:50.714" style="s2">We'll then place a sterile dressing,</p>
<p begin="00:05:50.714" end="00:05:53.268" style="s2">like the Tegaderm shown in<br />the picture to the upper right</p>
<p begin="00:05:53.268" end="00:05:56.699" style="s2">over the access site, and<br />obtain a chest radiograph</p>
<p begin="00:05:56.699" end="00:05:58.906" style="s2">after all high lines,<br />to look for placement</p>
<p begin="00:05:58.906" end="00:06:00.532" style="s2">of the tip of the catheter,</p>
<p begin="00:06:00.532" end="00:06:03.306" style="s2">and also to rule out a pneumothorax.</p>
<p begin="00:06:03.306" end="00:06:05.376" style="s2">An optimal approach to<br />facilitate compliance</p>
<p begin="00:06:05.376" end="00:06:07.665" style="s2">with the central line<br />bundle, is to create a</p>
<p begin="00:06:07.665" end="00:06:09.978" style="s2">dedicated central line<br />bundle cart that moves</p>
<p begin="00:06:09.978" end="00:06:13.256" style="s2">to the patient during<br />the actual procedure.</p>
<p begin="00:06:13.256" end="00:06:15.577" style="s2">On this dedicated<br />central line bundle cart,</p>
<p begin="00:06:15.577" end="00:06:17.600" style="s2">can be included all the supplies essential</p>
<p begin="00:06:17.600" end="00:06:21.053" style="s2">to central venous access, to<br />facilitate easy compliance</p>
<p begin="00:06:21.053" end="00:06:22.843" style="s2">with the steps.</p>
<p begin="00:06:22.843" end="00:06:26.065" style="s2">In the cart can be included<br />the chlorhexidine swabs,</p>
<p begin="00:06:26.065" end="00:06:28.905" style="s2">all the sterile barrier<br />supplies for the operator,</p>
<p begin="00:06:28.905" end="00:06:31.584" style="s2">such as the cap, gown and sterile gloves,</p>
<p begin="00:06:31.584" end="00:06:34.121" style="s2">the wide field barrier for our patient,</p>
<p begin="00:06:34.121" end="00:06:37.556" style="s2">sterile caps to go onto the<br />central venous catheter,</p>
<p begin="00:06:37.556" end="00:06:40.305" style="s2">and the dressing cover, the<br />Tegaderm to cover the site</p>
<p begin="00:06:40.305" end="00:06:42.731" style="s2">after the procedure is completed.</p>
<p begin="00:06:42.731" end="00:06:44.681" style="s2">One should also have the ultrasound probe</p>
<p begin="00:06:44.681" end="00:06:47.194" style="s2">sterile sheath cover,<br />to facilitate the use of</p>
<p begin="00:06:47.194" end="00:06:50.779" style="s2">ultrasound in a sterile<br />manner during the procedure.</p>
<p begin="00:06:50.779" end="00:06:52.428" style="s2">A crucial step that's<br />more relevant for the</p>
<p begin="00:06:52.428" end="00:06:55.004" style="s2">critical care units, is<br />a daily review of all</p>
<p begin="00:06:55.004" end="00:06:58.843" style="s2">central venous lines to see<br />if the line is truly needed.</p>
<p begin="00:06:58.843" end="00:07:01.489" style="s2">All unessential lines should<br />be immediately removed</p>
<p begin="00:07:01.489" end="00:07:04.456" style="s2">from the patient, if not essential<br />for optimal patient care,</p>
<p begin="00:07:04.456" end="00:07:07.729" style="s2">to decrease the risk of<br />infections to our patients.</p>
<p begin="00:07:07.729" end="00:07:10.761" style="s2">So in conclusion, the central<br />venous access six point bundle</p>
<p begin="00:07:10.761" end="00:07:13.329" style="s2">can potentially decrease<br />the complication rate</p>
<p begin="00:07:13.329" end="00:07:16.139" style="s2">for our patients<br />undergoing this procedure.</p>
<p begin="00:07:16.139" end="00:07:18.348" style="s2">Remember that we get<br />to the six point bundle</p>
<p begin="00:07:18.348" end="00:07:21.032" style="s2">by adding ultrasound<br />guidance of line placement</p>
<p begin="00:07:21.032" end="00:07:24.753" style="s2">to the IHI five point<br />recommendations as shown below.</p>
<p begin="00:07:24.753" end="00:07:28.760" style="s2">Hand hygiene, skin antisepsis,<br />maximal barrier precautions,</p>
<p begin="00:07:28.760" end="00:07:31.471" style="s2">catheter site selection,<br />going for those high lines</p>
<p begin="00:07:31.471" end="00:07:33.809" style="s2">over the low lines, and<br />a daily review of the</p>
<p begin="00:07:33.809" end="00:07:36.040" style="s2">need for a central line.</p>
<p begin="00:07:36.040" end="00:07:37.015" style="s2">Through adherence to the</p>
<p begin="00:07:37.015" end="00:07:39.224" style="s2">central venous access six point bundle,</p>
<p begin="00:07:39.224" end="00:07:42.167" style="s2">we can potentially make the<br />central venous access procedure</p>
<p begin="00:07:42.167" end="00:07:44.425" style="s2">a safer one for our patients.</p>
<p begin="00:07:44.425" end="00:07:46.447" style="s2">Remember that, number<br />one, we can potentially</p>
<p begin="00:07:46.447" end="00:07:48.713" style="s2">lower the rate of mechanical complications</p>
<p begin="00:07:48.713" end="00:07:51.688" style="s2">by using ultrasound guidance<br />throughout the procedure.</p>
<p begin="00:07:51.688" end="00:07:53.855" style="s2">And number two, we can<br />potentially lower the rate of</p>
<p begin="00:07:53.855" end="00:07:56.129" style="s2">infectious complications of the procedure,</p>
<p begin="00:07:56.129" end="00:08:00.110" style="s2">by close adherence to the IHI guidelines.</p>
<p begin="00:08:00.110" end="00:08:02.815" style="s2">In conclusion, hopefully<br />we can make hospitalization</p>
<p begin="00:08:02.815" end="00:08:05.143" style="s2">a potentially safer<br />experience for the most ill</p>
<p begin="00:08:05.143" end="00:08:07.897" style="s2">of our patients who are<br />receiving central venous access,</p>
<p begin="00:08:07.897" end="00:08:10.230" style="s2">for their treatments.</p>
<p begin="00:08:10.230" end="00:08:12.137" style="s2">So I hope to see you back in the future,</p>
<p begin="00:08:12.137" end="00:08:14.220" style="s2">as Soundbytes continues.</p>
<p begin="00:00:17.038" end="00:00:19.563" style="s2">how we can improve patient<br />safety through a concept</p>
<p begin="00:00:19.563" end="00:00:22.099" style="s2">known as a central line bundle.</p>
<p begin="00:00:22.099" end="00:00:24.924" style="s2">Now the central line bundle<br />is a six step checklist</p>
<p begin="00:00:24.924" end="00:00:28.016" style="s2">of initiatives that can<br />decrease both the infectious,</p>
<p begin="00:00:28.016" end="00:00:32.183" style="s2">and mechanical complications<br />of central line placement.</p>
<p begin="00:00:33.620" end="00:00:35.340" style="s2">Let's begin this module<br />by going over some of the</p>
<p begin="00:00:35.340" end="00:00:39.054" style="s2">potential patient benefits<br />of central venous access.</p>
<p begin="00:00:39.054" end="00:00:41.940" style="s2">Central venous access allows more secure</p>
<p begin="00:00:41.940" end="00:00:44.462" style="s2">vascular access in our sickest patients,</p>
<p begin="00:00:44.462" end="00:00:46.324" style="s2">and gives us the ability to deliver</p>
<p begin="00:00:46.324" end="00:00:49.407" style="s2">high flow infusions in these patients.</p>
<p begin="00:00:49.407" end="00:00:52.787" style="s2">Central venous access is also<br />a safer administration route</p>
<p begin="00:00:52.787" end="00:00:56.248" style="s2">of vasopressors as opposed<br />to the peripheral route.</p>
<p begin="00:00:56.248" end="00:00:59.137" style="s2">A central line allows for<br />better hemodynamic monitoring</p>
<p begin="00:00:59.137" end="00:01:01.537" style="s2">of our patients, allowing you to monitor</p>
<p begin="00:01:01.537" end="00:01:04.305" style="s2">central venous pressure, or CVP, and also</p>
<p begin="00:01:04.305" end="00:01:06.888" style="s2">mixed venous oxygen saturation.</p>
<p begin="00:01:07.895" end="00:01:10.166" style="s2">However there are some<br />serious patient risks involved</p>
<p begin="00:01:10.166" end="00:01:12.559" style="s2">with placement of a<br />central venous catheter.</p>
<p begin="00:01:12.559" end="00:01:15.366" style="s2">The two main groups of<br />complications are the mechanical,</p>
<p begin="00:01:15.366" end="00:01:17.102" style="s2">and the infectious.</p>
<p begin="00:01:17.102" end="00:01:19.751" style="s2">Those included under<br />mechanical complications are</p>
<p begin="00:01:19.751" end="00:01:23.518" style="s2">pneumothorax formation,<br />hemothorax formation,</p>
<p begin="00:01:23.518" end="00:01:28.481" style="s2">and inadvertent arterial<br />puncture with hematoma formation.</p>
<p begin="00:01:28.481" end="00:01:31.639" style="s2">The second main category are<br />the infectious complications</p>
<p begin="00:01:31.639" end="00:01:33.854" style="s2">and central associated<br />bloodstream infections</p>
<p begin="00:01:33.854" end="00:01:36.144" style="s2">are increasingly recognized<br />cause of increased</p>
<p begin="00:01:36.144" end="00:01:39.972" style="s2">morbidity and mortality<br />in our sickest patients.</p>
<p begin="00:01:39.972" end="00:01:41.812" style="s2">Because of these<br />recognized complications of</p>
<p begin="00:01:41.812" end="00:01:45.197" style="s2">central line placement, bedside<br />ultrasound has stepped up</p>
<p begin="00:01:45.197" end="00:01:47.980" style="s2">to help us lower the complication rate.</p>
<p begin="00:01:47.980" end="00:01:50.084" style="s2">Bedside ultrasound dramatically decreases</p>
<p begin="00:01:50.084" end="00:01:53.124" style="s2">the mechanical complications<br />of central line placement,</p>
<p begin="00:01:53.124" end="00:01:55.508" style="s2">allowing real time guidance<br />of the cannulating needle</p>
<p begin="00:01:55.508" end="00:01:57.484" style="s2">into the central vein.</p>
<p begin="00:01:57.484" end="00:02:00.440" style="s2">Bedside ultrasound is now recommended by</p>
<p begin="00:02:00.440" end="00:02:03.420" style="s2">governmental agencies and<br />multiple medical societies</p>
<p begin="00:02:03.420" end="00:02:06.994" style="s2">as an aid in placement of central lines.</p>
<p begin="00:02:06.994" end="00:02:09.219" style="s2">And over recent years there's<br />been increasing momentum</p>
<p begin="00:02:09.219" end="00:02:10.597" style="s2">in initiatives to decrease</p>
<p begin="00:02:10.597" end="00:02:13.373" style="s2">central line associated infections.</p>
<p begin="00:02:13.373" end="00:02:17.753" style="s2">Two major initiatives were<br />the IHI 100,000 Lives Campaign</p>
<p begin="00:02:17.753" end="00:02:20.514" style="s2">which came out in 2005,<br />with the aim to improve</p>
<p begin="00:02:20.514" end="00:02:23.584" style="s2">patient safety in all USA hospitals.</p>
<p begin="00:02:23.584" end="00:02:26.969" style="s2">Also in 2006, the Joint Commissions, JCAHO</p>
<p begin="00:02:26.969" end="00:02:29.536" style="s2">came out with the Six<br />National Safety Goals,</p>
<p begin="00:02:29.536" end="00:02:31.529" style="s2">also with the aim of reducing risk of</p>
<p begin="00:02:31.529" end="00:02:34.265" style="s2">health care associated infections.</p>
<p begin="00:02:34.265" end="00:02:36.849" style="s2">The Institute for Health<br />Care Improvement, or IHI</p>
<p begin="00:02:36.849" end="00:02:39.639" style="s2">recommendations for central<br />venous access include</p>
<p begin="00:02:39.639" end="00:02:41.590" style="s2">five major initiatives.</p>
<p begin="00:02:41.590" end="00:02:44.797" style="s2">The first is increasing<br />attention to hand hygiene.</p>
<p begin="00:02:44.797" end="00:02:48.086" style="s2">Number two, adequate skin antisepsis,</p>
<p begin="00:02:48.086" end="00:02:51.190" style="s2">number three, maximal barrier precautions,</p>
<p begin="00:02:51.190" end="00:02:54.272" style="s2">number four, catheter site selection,</p>
<p begin="00:02:54.272" end="00:02:56.694" style="s2">and number five, daily review of the need</p>
<p begin="00:02:56.694" end="00:02:58.774" style="s2">for a central line.</p>
<p begin="00:02:58.774" end="00:03:01.838" style="s2">If one adds ultrasound<br />guidance of line placement</p>
<p begin="00:03:01.838" end="00:03:05.605" style="s2">to the five point IHI<br />recommendations of hand hygiene,</p>
<p begin="00:03:05.605" end="00:03:08.722" style="s2">skin antisepsis, maximal<br />barrier precautions,</p>
<p begin="00:03:08.722" end="00:03:11.463" style="s2">catheter site selection,<br />and daily review of the need</p>
<p begin="00:03:11.463" end="00:03:14.062" style="s2">for central line, one<br />gets to the central line</p>
<p begin="00:03:14.062" end="00:03:16.622" style="s2">six point bundle, the current standard</p>
<p begin="00:03:16.622" end="00:03:20.865" style="s2">for decreasing complications<br />of central line placement.</p>
<p begin="00:03:20.865" end="00:03:22.600" style="s2">Before performing central venous access,</p>
<p begin="00:03:22.600" end="00:03:25.587" style="s2">it's mandatory to perform a<br />checklist prior to the procedure</p>
<p begin="00:03:25.587" end="00:03:27.865" style="s2">to decrease the complication rate.</p>
<p begin="00:03:27.865" end="00:03:29.664" style="s2">The first thing one should do is to review</p>
<p begin="00:03:29.664" end="00:03:32.730" style="s2">the patient charts for those<br />increased procedural risks</p>
<p begin="00:03:32.730" end="00:03:35.553" style="s2">to our patients, such as coagulopathy,</p>
<p begin="00:03:35.553" end="00:03:38.520" style="s2">thrombocytopenia, the presence of a DVT</p>
<p begin="00:03:38.520" end="00:03:41.409" style="s2">within the upper extremity<br />or lower extremity veins,</p>
<p begin="00:03:41.409" end="00:03:43.649" style="s2">or a known latex allergy.</p>
<p begin="00:03:43.649" end="00:03:46.368" style="s2">One should obtain informed<br />consent from our patients,</p>
<p begin="00:03:46.368" end="00:03:49.416" style="s2">also performing a prescan<br />ultrasound to look for a clot</p>
<p begin="00:03:49.416" end="00:03:51.404" style="s2">in the targeted veins.</p>
<p begin="00:03:51.404" end="00:03:54.008" style="s2">Last but not least, it's<br />optimal and mandatory</p>
<p begin="00:03:54.008" end="00:03:56.136" style="s2">to perform a time out procedure together</p>
<p begin="00:03:56.136" end="00:03:57.988" style="s2">with the nursing staff.</p>
<p begin="00:03:57.988" end="00:04:00.432" style="s2">Going through the IHI<br />guidelines for decreasing</p>
<p begin="00:04:00.432" end="00:04:02.904" style="s2">the complication rate for<br />central venous access,</p>
<p begin="00:04:02.904" end="00:04:05.129" style="s2">the first step is to wash<br />your hands thoroughly</p>
<p begin="00:04:05.129" end="00:04:06.640" style="s2">prior to the procedure.</p>
<p begin="00:04:06.640" end="00:04:09.120" style="s2">As an alternative, one can<br />consider application of</p>
<p begin="00:04:09.120" end="00:04:12.273" style="s2">alcohol based, waterless<br />hand cleansers which offer</p>
<p begin="00:04:12.273" end="00:04:16.715" style="s2">additional disinfection benefit<br />over conventional washing.</p>
<p begin="00:04:16.715" end="00:04:19.092" style="s2">The second step for decreasing<br />the complication rate</p>
<p begin="00:04:19.092" end="00:04:21.403" style="s2">of central venous access,<br />is adequate attention</p>
<p begin="00:04:21.403" end="00:04:23.170" style="s2">to skin antisepsis.</p>
<p begin="00:04:23.170" end="00:04:26.474" style="s2">For this initiative, Chlorhexidine<br />is going to be optimal.</p>
<p begin="00:04:26.474" end="00:04:28.693" style="s2">Chlorhexidine offers<br />benefits over traditional</p>
<p begin="00:04:28.693" end="00:04:31.989" style="s2">Povidine-iodine with<br />regard to skin antisepsis,</p>
<p begin="00:04:31.989" end="00:04:34.132" style="s2">and it's best to scrub<br />the Chlorhexidine sponge</p>
<p begin="00:04:34.132" end="00:04:37.246" style="s2">vigorously across your<br />patient's skin for 20 seconds,</p>
<p begin="00:04:37.246" end="00:04:40.067" style="s2">applying three Chlorhexidine<br />scrubs sequentially</p>
<p begin="00:04:40.067" end="00:04:43.564" style="s2">to a wide field area<br />over the patient's skin.</p>
<p begin="00:04:43.564" end="00:04:45.361" style="s2">The third step is adequate attention to</p>
<p begin="00:04:45.361" end="00:04:47.329" style="s2">maximal barrier precautions during the</p>
<p begin="00:04:47.329" end="00:04:49.625" style="s2">central venous placement procedure.</p>
<p begin="00:04:49.625" end="00:04:52.681" style="s2">The operator and all<br />assistants should wear a cap,</p>
<p begin="00:04:52.681" end="00:04:54.939" style="s2">mask, sterile gown and sterile gloves</p>
<p begin="00:04:54.939" end="00:04:56.593" style="s2">throughout the procedure.</p>
<p begin="00:04:56.593" end="00:04:58.617" style="s2">It's important to place<br />a wide field barrier</p>
<p begin="00:04:58.617" end="00:05:00.321" style="s2">over the patient during the procedure</p>
<p begin="00:05:00.321" end="00:05:03.129" style="s2">to decrease the infectious<br />risk to our patient.</p>
<p begin="00:05:03.129" end="00:05:05.298" style="s2">The patient should be<br />covered from head to toe</p>
<p begin="00:05:05.298" end="00:05:08.113" style="s2">with this wide field barrier,<br />with only a small opening</p>
<p begin="00:05:08.113" end="00:05:11.075" style="s2">for the insertion site<br />of the central line.</p>
<p begin="00:05:11.075" end="00:05:13.361" style="s2">The fourth main step<br />within the IHI guidelines,</p>
<p begin="00:05:13.361" end="00:05:15.346" style="s2">is adequate attention to site selection</p>
<p begin="00:05:15.346" end="00:05:17.738" style="s2">for placement of a<br />central venous catheter.</p>
<p begin="00:05:17.738" end="00:05:20.146" style="s2">In general, high lines are preferred.</p>
<p begin="00:05:20.146" end="00:05:22.591" style="s2">The internal jugular<br />vein and subclavian vein</p>
<p begin="00:05:22.591" end="00:05:24.443" style="s2">are associated with a decreased risk of</p>
<p begin="00:05:24.443" end="00:05:27.477" style="s2">infectious complications to our patients.</p>
<p begin="00:05:27.477" end="00:05:29.867" style="s2">In general, low lines are less preferred,</p>
<p begin="00:05:29.867" end="00:05:32.292" style="s2">as placement of a catheter<br />into the femoral vein</p>
<p begin="00:05:32.292" end="00:05:34.555" style="s2">is associated with<br />higher risk of infection,</p>
<p begin="00:05:34.555" end="00:05:38.603" style="s2">and also a higher risk<br />of DVT in our patients.</p>
<p begin="00:05:38.603" end="00:05:40.371" style="s2">Critical actions following placement of a</p>
<p begin="00:05:40.371" end="00:05:43.611" style="s2">central venous catheter<br />include using sterile technique</p>
<p begin="00:05:43.611" end="00:05:46.253" style="s2">to flush all lines of the<br />catheter, and then putting</p>
<p begin="00:05:46.253" end="00:05:49.035" style="s2">sterile catheter caps on all lumens.</p>
<p begin="00:05:49.035" end="00:05:50.714" style="s2">We'll then place a sterile dressing,</p>
<p begin="00:05:50.714" end="00:05:53.268" style="s2">like the Tegaderm shown in<br />the picture to the upper right</p>
<p begin="00:05:53.268" end="00:05:56.699" style="s2">over the access site, and<br />obtain a chest radiograph</p>
<p begin="00:05:56.699" end="00:05:58.906" style="s2">after all high lines,<br />to look for placement</p>
<p begin="00:05:58.906" end="00:06:00.532" style="s2">of the tip of the catheter,</p>
<p begin="00:06:00.532" end="00:06:03.306" style="s2">and also to rule out a pneumothorax.</p>
<p begin="00:06:03.306" end="00:06:05.376" style="s2">An optimal approach to<br />facilitate compliance</p>
<p begin="00:06:05.376" end="00:06:07.665" style="s2">with the central line<br />bundle, is to create a</p>
<p begin="00:06:07.665" end="00:06:09.978" style="s2">dedicated central line<br />bundle cart that moves</p>
<p begin="00:06:09.978" end="00:06:13.256" style="s2">to the patient during<br />the actual procedure.</p>
<p begin="00:06:13.256" end="00:06:15.577" style="s2">On this dedicated<br />central line bundle cart,</p>
<p begin="00:06:15.577" end="00:06:17.600" style="s2">can be included all the supplies essential</p>
<p begin="00:06:17.600" end="00:06:21.053" style="s2">to central venous access, to<br />facilitate easy compliance</p>
<p begin="00:06:21.053" end="00:06:22.843" style="s2">with the steps.</p>
<p begin="00:06:22.843" end="00:06:26.065" style="s2">In the cart can be included<br />the chlorhexidine swabs,</p>
<p begin="00:06:26.065" end="00:06:28.905" style="s2">all the sterile barrier<br />supplies for the operator,</p>
<p begin="00:06:28.905" end="00:06:31.584" style="s2">such as the cap, gown and sterile gloves,</p>
<p begin="00:06:31.584" end="00:06:34.121" style="s2">the wide field barrier for our patient,</p>
<p begin="00:06:34.121" end="00:06:37.556" style="s2">sterile caps to go onto the<br />central venous catheter,</p>
<p begin="00:06:37.556" end="00:06:40.305" style="s2">and the dressing cover, the<br />Tegaderm to cover the site</p>
<p begin="00:06:40.305" end="00:06:42.731" style="s2">after the procedure is completed.</p>
<p begin="00:06:42.731" end="00:06:44.681" style="s2">One should also have the ultrasound probe</p>
<p begin="00:06:44.681" end="00:06:47.194" style="s2">sterile sheath cover,<br />to facilitate the use of</p>
<p begin="00:06:47.194" end="00:06:50.779" style="s2">ultrasound in a sterile<br />manner during the procedure.</p>
<p begin="00:06:50.779" end="00:06:52.428" style="s2">A crucial step that's<br />more relevant for the</p>
<p begin="00:06:52.428" end="00:06:55.004" style="s2">critical care units, is<br />a daily review of all</p>
<p begin="00:06:55.004" end="00:06:58.843" style="s2">central venous lines to see<br />if the line is truly needed.</p>
<p begin="00:06:58.843" end="00:07:01.489" style="s2">All unessential lines should<br />be immediately removed</p>
<p begin="00:07:01.489" end="00:07:04.456" style="s2">from the patient, if not essential<br />for optimal patient care,</p>
<p begin="00:07:04.456" end="00:07:07.729" style="s2">to decrease the risk of<br />infections to our patients.</p>
<p begin="00:07:07.729" end="00:07:10.761" style="s2">So in conclusion, the central<br />venous access six point bundle</p>
<p begin="00:07:10.761" end="00:07:13.329" style="s2">can potentially decrease<br />the complication rate</p>
<p begin="00:07:13.329" end="00:07:16.139" style="s2">for our patients<br />undergoing this procedure.</p>
<p begin="00:07:16.139" end="00:07:18.348" style="s2">Remember that we get<br />to the six point bundle</p>
<p begin="00:07:18.348" end="00:07:21.032" style="s2">by adding ultrasound<br />guidance of line placement</p>
<p begin="00:07:21.032" end="00:07:24.753" style="s2">to the IHI five point<br />recommendations as shown below.</p>
<p begin="00:07:24.753" end="00:07:28.760" style="s2">Hand hygiene, skin antisepsis,<br />maximal barrier precautions,</p>
<p begin="00:07:28.760" end="00:07:31.471" style="s2">catheter site selection,<br />going for those high lines</p>
<p begin="00:07:31.471" end="00:07:33.809" style="s2">over the low lines, and<br />a daily review of the</p>
<p begin="00:07:33.809" end="00:07:36.040" style="s2">need for a central line.</p>
<p begin="00:07:36.040" end="00:07:37.015" style="s2">Through adherence to the</p>
<p begin="00:07:37.015" end="00:07:39.224" style="s2">central venous access six point bundle,</p>
<p begin="00:07:39.224" end="00:07:42.167" style="s2">we can potentially make the<br />central venous access procedure</p>
<p begin="00:07:42.167" end="00:07:44.425" style="s2">a safer one for our patients.</p>
<p begin="00:07:44.425" end="00:07:46.447" style="s2">Remember that, number<br />one, we can potentially</p>
<p begin="00:07:46.447" end="00:07:48.713" style="s2">lower the rate of mechanical complications</p>
<p begin="00:07:48.713" end="00:07:51.688" style="s2">by using ultrasound guidance<br />throughout the procedure.</p>
<p begin="00:07:51.688" end="00:07:53.855" style="s2">And number two, we can<br />potentially lower the rate of</p>
<p begin="00:07:53.855" end="00:07:56.129" style="s2">infectious complications of the procedure,</p>
<p begin="00:07:56.129" end="00:08:00.110" style="s2">by close adherence to the IHI guidelines.</p>
<p begin="00:08:00.110" end="00:08:02.815" style="s2">In conclusion, hopefully<br />we can make hospitalization</p>
<p begin="00:08:02.815" end="00:08:05.143" style="s2">a potentially safer<br />experience for the most ill</p>
<p begin="00:08:05.143" end="00:08:07.897" style="s2">of our patients who are<br />receiving central venous access,</p>
<p begin="00:08:07.897" end="00:08:10.230" style="s2">for their treatments.</p>
<p begin="00:08:10.230" end="00:08:12.137" style="s2">So I hope to see you back in the future,</p>
<p begin="00:08:12.137" end="00:08:14.220" style="s2">as Soundbytes continues.</p>
Brightcove ID
5508123477001
https://youtube.com/watch?v=hUH-B7qy-fc