M. R. Threlkeld1, J. P. Gurria1, D. Doellman1, E. S. Tuncel Kara1, M. Troutt1, B. Rymeski1, R. A. Falcone1 1Cincinnati Childrens Hospital And Medical Center,Pediatric Surgery,Cincinnati, OH, USA
Introduction: Central venous catheters (CVC) are ubiquitous, carrying greater than 15% risk of complications including vascular damage, thrombosis, and infection. There are several recommendations to consider when evaluating a patient and selecting an appropriate catheter. At our pediatric hospital inappropriate line selection and improper pre-operative evaluation lead to OR inefficiency, more procedures for patients, and ultimately increased risks of complications. We therefore created a care algorithm as a quality improvement project to standardize proper line selection, identify high risk patients, and improve efficiency with decreased complications.
Methods: Current central venous access recommendations and evidence based literature were used to create a CVC care algorithm. A consensus was reached between all members of the surgical team, vascular access team, and oncology team. The CVC care algorithm (FIGURE 1) selects the appropriate central venous line based on the type of therapy, the infusion risk level, the duration of therapy, and the frequency of therapy. Patients that may not benefit from a CVC are identified and an alternative device is recommended. Patients requiring a CVC are stratified into high, intermediate, or low risk based on prior history of lines, complication profile, laboratory values including platelet count, body habitus, and renal failure. Pre-operative evaluation is then determined based on the patient’s risk level and may include further vascular imaging with ultrasound or MRI and correction of abnormal laboratory values. The care algorithm was implemented and data were collected manually from patient charts retrospectively between April 2016 and June 2017. Given inconsistencies in utilizing the algorithm, a consult note template was added to the electronic medical record to allow practitioners to use the care algorithm more easily and consistently.
Results: A total of 159 inpatients had a central line placed with 68% screened utilizing the algorithm overall but with an 86% screen rate after implementation of the standardized template consult note. Of these patients, 33.7% were classified high risk and had appropriate imaging identifying abnormal anatomy in 32.3% that helped direct line placement. Utilization of our central line dedicated OR block time increased from 65% to 80% as well over this period.
Conclusion: Our multi-disciplinary pediatric team has developed and implemented a standardized care algorithm for the selection and pre-operative risk stratification to improve the safety and efficiency of central line placement in children. Longer term follow up will be necessary to further document the impact on patient safety requiring central venous access in our hospital.
