Clinician Unaware of Central Line in 20% of Inpatients

Veronica Hackethal, MD

October 21, 2014

About 20% of clinicians at various levels of training were unaware of the placement of a central line in their hospitalized patients, according to a study published in the October 21 issue of the Annals of Internal Medicine.

"[T]his is the first study that examines how often clinicians in various locations, training levels, and specialities are unaware of the presence of [central venous catheters (CVCs)]," write Vineet Chopra, MD, from the University of Michigan in Ann Arbor, and colleagues.

"[T]eaching attendings and hospitalists were least likely to be aware of CVC presence," they add, "Because early removal of CVCs requires knowledge of their presence, these findings have important patient safety and policy implications for providers and health systems worldwide."

Although central venous catheters provide venous access for monitoring blood pressure and perfusion of vital organs, as well as delivery of medications such as antibiotics and chemotherapy, there are risks associated with their use. In addition, the risk of complications increases with longer duration of CVC placement, making prompt removal desirable when no longer necessary.

To learn how often clinicians were aware or unaware that a patient had a CVC, Dr Chopra and colleagues interviewed responsible clinicians at three academic medical centers in the United States between April 2012 and September 2013. The researchers interviewed them about the presence of CVCs in their patients after morning rounds. The investigators also interviewed patients in intensive care unit (ICU) and non-ICU settings and performed physical exams looking for the presence of a peripherally inserted central catheter (PICC) line or triple lumen catheter.

Of 990 patients included, 21.1% had CVCs, and 60.3% of these were PICC lines. Ninety (21.2%) of the 425 responsible clinicians did not know about the presence of a CVC in their patients. (Notably, 5.6% of clinicians thought a patient had a CVC when the investigators' own exam did not find one.)

Nearly one in five (19.1%) interns were unaware of a CVC in their patients, and almost 13.8% of medical residents were unaware. General medicine teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than house staff members (25.8% and 30.5%, respectively, vs 16.4%; P = .031 and P = .014, respectively).

The authors hypothesize that clinicians, such as critical care physicians, who often place CVCs would have a greater awareness than general physicians and that proved to be correct, with just 12.6% of critical care physicians being unaware of a CVC compared with 26.2% of general medicine physicians and hospitalists (P = .003).

Similarly, clinicians in non-ICU settings had more unawareness about CVCs compared with those in ICUs (24.8% vs 12.6%, respectively; P = .005).

When the authors just considered PICC lines, they found that about 25% of clinicians were unaware of the presence of the devices. The authors pointed out the importance of these latter findings, as PICC lines have become more common in non-ICU settings nationwide.

"[O]ur study suggests that relying on frontline clinicians who are responsible for CVC care to remove these devices may not be ideal," the authors write. "Rather, multidisciplinary approaches that incorporate bedside and vascular nursing, infection preventionist, and clinician review of the presence and necessity of CVCs seem necessary."

The "rate of unawareness is troubling," writes Darren B. Taichman, MD, PhD, executive deputy editor of the Annals of Internal Medicine, in an accompanying editorial.

Dr Taichman points to the value of safety checklists and daily assessments of CVCs. He also suggests that all providers responsible for a patient's care, not just the infection control team, track duration of CVC placement. However, even these measures will not be enough, he says.

"[I]t irks me that we would be comfortable being unaware that a dangerous implement we inserted into the patient's body remains and might no longer be needed," Dr Taichman asserted. "We have sworn to do no harm, and eliminating unneeded and threatening interventions is part of keeping that promise."

Referring to the editorial's title, "Whose Line Is It Anyway," taken from the improvisational comedy show, Dr Taichman concludes: "I believe that we should 'memorize our lines' and then be mindful as we deliver them. If we ignore our lines completely, however, I would argue that we should get off of the stage."

Dr Chopra reports a patent pending on technology that tracks the presence and duration of CVCs. One or more authors reports honoraria, grants, patents, or royalties from one or more of the following: VHA Premier, Michigan Health and Hospitals Association, IHI, Doximity, Jvion, and the Blue Cross Blue Shield of Michigan Foundation. Dr Taichman has disclosed no relevant financial relationships.

Ann Intern Med. 2014;161:562-567, 607-608. Article abstract, Editorial extract

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