COMMENTARY

Outcomes of Nurse-Inserted Central Venous Catheters

Laurie Scudder, DNP, NP

Disclosures

March 08, 2012

Nurse-Led Central Venous Catheter Insertion -- Procedural Characteristics and Outcomes of Three Intensive Case Based Catheter Placement Services

Alexandrou E, Murgo M, Calabria E, et al.
Int J Nurs Stud. 2012;49:162-168.

Study Summary

Background. Insertion of central venous catheters (CVCs) has historically been a task limited to physicians. However, as the use of CVCs and peripherally inserted central catheters (PICCs) has become more commonplace, nurse-led models for insertion and care of these vascular lines have developed. Previous research has shown the importance of procedural volume in attaining competency in CVC insertion and in achieving optimal patient- and catheter-related outcomes. The purpose of this study was to examine the outcomes of central lines placed by nurses in hospitals with high procedural volume.

Methodology. Central line-associated bacteremia (CLAB) is a well-recognized and potentially lethal complication of CVC placement. In an attempt to reduce these serious infections, hospitals in New South Wales, Australia, participated in a quality-improvement initiative aimed at promoting aseptic insertion technique and reducing the incidence of CLABs. The Central Line Associated Bacteremia-Intensive Care Unit (CLAB-ICU) project took place in all adult and pediatric intensive care units (ICUs) in the state between March 2007 and June 2009. The researchers collected deidentified data about CVCs inserted by nurses.

Results. Data were collected on 760 nurse-led placements of vascular access devices (VADs) that occurred during the study period, which represented approximately 5% of all of VAD insertions in ICUs throughout the catchment area. The 3 hospitals from which data were collected were all university affiliated and ranged in size from 420 to 650 beds. The types of devices varied among the institutions, but PICCs were the most common catheters inserted in all 3 facilities. Use of ultrasound-guided vascular access also varied. Although ICUs were the most common setting in which catheters were placed in all facilities, in one of the hospitals a few nurse-led insertions took place in other areas, including the emergency department and outpatient settings. Nurses in one of the hospitals used antiseptic-coated catheters or antibacterial catheters for a small percentage of procedures (23%), whereas the catheters inserted in the other 2 facilities were nearly all noncoated.

Complications associated with CVC insertions at all of the hospitals were minimal. One hospital recorded 1 case of pneumothorax and 1 catheter malposition. Another facility documented catheter malpositions in 7 insertions and a single arterial puncture. Only 1 CLAB was documented during the study period, which resulted in a nursing CLAB rate in aggregate of 1.3 per 1000 catheters inserted (95% confidence interval [CI], 0.03-7.3), in comparison with a rate of 7.2 CLABs per 1000 insertions (95% CI, 5.9-8.7) for all CVC insertions that occurred during the study period. The documented rate of compliance with full aseptic technique for the nurse-led insertions was 100% compared with a compliance rate of 92% for all insertions in the CLAB-ICU data.

Viewpoint

The mere fact of being observed is known to alter behavior, so it must be recognized that the very low incidence of CLABs that occurred following these nurse-led insertions could be due, at least in part, to the insertions having taken place during a quality-improvement project and that participants knew that CLAB data were being collected. However, that caveat would apply to all clinicians inserting lines during the observation period. Also, the nurse-led CVC placements took place almost exclusively in ICUs rather than in emergency departments, so patients may have been more stable and less acutely ill. Finally, there are inherent confounders when using a retrospective dataset that must be considered in interpreting results. Despite these limitations, the sheer size of the dataset is impressive. It adds to a growing body of evidence that nurses can and must provide services for which they are capable and trained and that allowing nurses to function within the full scope of their licensure and education will only increase the efficiency of the healthcare system and improve patient satisfaction and outcomes.

Abstract

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....