central line audit cycle
DESCRIPTION
Central Line Audit Cycle. Dr Coralie Carle B Med Sci BMBS FRCA, SpR 4 Anaesthesia & ICM Dr Ibrahim Ibrahim, MBChB ST 2 Anaesthesia Dr Simon Mills, MBChB MRCP FRCA, Consultant Anaesthetist. Outline. trigger for audit background service evaluation intervention re-audit future plans. - PowerPoint PPT PresentationTRANSCRIPT
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Central Line Audit Cycle
Dr Coralie Carle B Med Sci BMBS FRCA, SpR 4 Anaesthesia & ICM
Dr Ibrahim Ibrahim, MBChB ST 2 Anaesthesia
Dr Simon Mills, MBChB MRCP FRCA, Consultant Anaesthetist
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Outline trigger for audit background service evaluation intervention re-audit future plans
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Audit Trigger
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Patient in PACU… 37 year old male
post-op exploration of bleeding pseudoaneurysm / ileofemoral bypass
PMH• IVDU• Hep C +ve• PE
(patient consent for presentation obtained)
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…in extremis acutely SOB in PACU
ABC approach with simultaneous consideration of diagnoses• pneumothorax• PE• transfusion reaction• air embolism
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CVC inspection 3-way stopcock aligned so it was
potentially open to the atmosphere partially loose (cross threaded) red
replacement cap air aspirated from lumen < 1 ml lumen flushed & cap tightened
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Venous Air Embolism (VAE) Suspected
left lateral decubitus position
distal lumen of CVC aspirated• No further air withdrawn
AP mobile erect CXR taken to aid diagnosis
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reduction in upper zone vascular markings
7mm x 19mm gas shadow region of the left main pulmonary artery
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Supportive Management sat up as most comfortable
100% oxygen
gradual improvement over 30 minutes
discharged at 90 minutes• oxygen• level 2 care
follow up revealed no persistent problems
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Venous Air Embolism
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VAE development open communication
• between vein & atmosphere
pressure gradient enabling air entrainment• Vessel lumen : atmospheric pressure
volume and rate of air entrained• size of communication• pressure gradient
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100mls can be fatal1 100mls:
• 14G cannula• 1 second • 5cm H20 pressure gradient2
90mls: • 8F PAC introducer needle• 1 second• 5.4cm H20 pressure gradient3
§ Yeakel AE. Lethal air embolism from plastic blood-storage container. Journal of the American Medical Association 1968; 204: 267-9.
§ Flanagan JP, Gradisar IA, Gross RJ, Kelly TR. Air embolus – a lethal complication of subclavian venipuncture. New England Journal of Medicine 1969; 218(9): 488-9.
§ Conahan TJ. Air embolization during percutaneous Swan-Ganz catheter placement. Anesthesiology 1979; 50: 360-1.
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Pressure gradient relative position of open communication
in relation to the RA• sitting position reduced CVP• resulted in the open communication of CVC
lying above RA hydration status
• Hypovolaemia decreases intravascular pressure
mode of ventilation• Spontaneous inspiration decreases
intravascular pressure CVP gasp reflex
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Gasp reflex VAE during spontaneous ventilation
10% obstruction to the pulmonary circulation can cause GASP REFLEX
reduces RA pressures and results in further air entrainment1
1. Palmon SC, Moore LE, Lundberg J, Toung T. Venous Air Embolism: A Review. Journal of Clinical Anesthesia 1997; 9: 251-7.
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Central Line Service Evaluation
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Outline R & D permission obtained Phase 1
• Assess current practice of CVC care in relation to prevention of VAE in all locations throughout the hospital
• Presentation of results Phase 2
• Assess need for standard setting• Implement agreed standard
Phase 3• Audit at 1 & 6 months post intervention
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Data collection proformaAudit ID number: Location: Bed number: CVC
Site R L IntJug Subclavian FemoralLumens in total 1 2 3 4 5Lumens in use 1 2 3 4 5Reason for CVCSpeciality/Grade of Dr inserting line Insertion date
SuturesFixed connector sutured Y NAdjustable connector present Y N & sutured Y NComments
DressingCovering insertion site Y NClean Y N
What position should the patient be in when removing the CVC?(ask nurse looking after patient)
Bung Bionector Tap position Clip open Clip Closed X Leave blank if no clipIf single bionector attached to lumen then write BIONECTOR across diagram
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Data collection Wed 28th Oct 2009 all wards in hospital
• ICU, HDU, CICU, CCU, medical & surgical wards, PACUs.
all patients with CVC in situ included in the evaluation
data collection proforma completed for each CVC
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Results: common errors
Patient
IVI
Patient
Patient
3 way Tap
CVC lumen
IVI
Patient
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Intervention
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Intervention presentation locally
• raised awareness• ensure CVC chosen is appropriate• use of three-way taps?
hospital standard set
re-education• Poster
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CVC insertion site:CVC sutured to the skin at all timesInsertion site covered by an occlusive dressing
Removal: Follow trust guidelines but remember to:Lie the patient head downApply a sterile occlusive dressing
Prevent air from entering CVC:Prime all syringes & IV giving setsUse needle-free access devices if possibleEnsure bungs are not cross-threadedEnsure correct 3-way-tap alignment:
1. Service evaluation Oct 09:
✗ ✗ ✗
Prevention of Venous Air Embolism (VAE):Central Venous Catheter (CVC) Care
% of CVCs with errors potentially leading to VAE
2. Intervention: Points to remember
3. Re-audit planned summer 2010
64% of CVCs had an error64% of CVCs at risk of VAE
✓✓
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Re-audit
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What next?
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What next? repeat education / updated posters
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CVC insertion site:CVC sutured to the skin at all timesInsertion site covered by an occlusive dressing
Removal: Follow trust guidelines but remember to:Lie the patient head downApply a sterile occlusive dressing
Prevent air from entering CVC:Prime all syringes & IV giving setsUse needle-free access devices if possibleEnsure bungs are not cross-threadedEnsure correct 3-way-tap alignment:
1. Current practice:
✗ ✗ ✗
Prevention of Venous Air Embolism (VAE):Central Venous Catheter (CVC) Care
% of CVCs with errors potentially leading to VAE
2. Intervention: Points to remember
3. Re-audit planned Nov 2010
Oct 09: 64% of CVCs at risk of VAEMay 10: 35% of CVCs at risk of VAE
✓✓
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What next? repeat education / updated posters
needle-less valves?
re-audit 6 months
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Summary
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Summary raised awareness relating to VAE
• prevention• management
our hospital’s approach consider…
• need for CVC?• lumens required?• needle-free valves?
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ANY QUESTION
S?