Doctor of Nursing Practice Program

• Committee Chair Name & Credentials:
  Jennifer Barut, PhD, MSN, RN
• Committee Member Name & Credentials:
  Teri Allison, DNP, RN, ACNP-BC

DNP Project Abstract

Ultrasound: Improving Standardization of Central Venous Catheter Confirmation

Purpose
Chest Xray confirmation of CVC tip has proven successful when central lines were used primarily for central venous pressure monitoring. Location of the CVC was of importance for accurate pressure measurement. With improved ultrasound technology, POCUS has gained recognition as a safe, reliable, and effective way to confirm CVC placement and rule out any iatrogenic complications secondary to the improvement of ultrasound technology. Utilization of chest Xray can result in an unnecessary delay of administration of vasopressors, other life-sustaining medications, or blood products due to the widely varied times for acquisition of a chest Xray. The purpose of this project was to demonstrate that POCUS is a safe and cost-effective alternative to chest Xray for CVC line placement.

Methods
This was a pilot procedural improvement project designed to reduce the use of chest Xray for every CVC confirmation and increase the utilization of POCUS for CVC confirmation. A CVC stepwise checklist was developed under the direction of the ICU medical director, the APP lead for the ICU, and the principal investigator. After the study period, a post-pilot analysis of critical care providers' feasibility of POCUS imaging acquisition for CVC confirmation was completed. Also, a comparison of the acquired ultrasound image interpretation by the critical care provider was compared with the radiologist x-ray interpretation for CVC confirmation. Last, a comparison of  time to confirmation between POCUS and chest Xray was evaluated to determine if practice change will be useful.

Results
Analysis of data shows a mean time to confirmation of the central line with ultrasound of 5.6 minutes, this was compared to the time from completion of the procedure to the acquisition of a chest Xray at bedside of 26.6 minutes. In the intensive care unit (ICU), all chest Xray’s are interpreted by the critical care provided at the bedside on the digital Xray machine screen. Ultrasound confirmation provided a decrease of 21 minutes in confirmation of the central line compared to obtainment of a chest Xray. This time is valuable for the treatment of patients and allows administration of needed treatment 21 minutes sooner. When interpreting the data, time from the chest Xray being obtained at the bedside to an official interpretation of the chest Xray by a radiologist was 58.8 minutes. If the chest Xray was not interpreted by the critical care provider at the bedside and one was to wait on the radiologist interpretation of the chest Xray, conformation would be 53.2 minutes later, compared to confirmation with ultrasound. With these eight central line placements, ultrasound was feasible in 87.5% of the placements or 7 out of the 8 central lines was able to be confirmed with ultrasound. On review of the critical care providers documentation of the seven central lines that was confirmed by visualization of a rapid atrial swirl sign in two seconds or less and no identified post procedural complications was compared to the Xray interpretation by the radiologist showed comparison rate of 100% accuracy. Meaning that the ultrasound confirmation and interpretation by the critical care provider matched that of the radiologist interpretation of the chest Xray for confirmation of central line placement.

Implications for Practice
Implementing POCUS reduces time to confirmation and provides an alternative to chest Xray when unavailable, improving patient care, especially in the critically ill. POCUS can also provide earlier confirmation for  CVC positioning in the superior vena cava, reducing the time to utilization of the line and identification of any post procedural complications. Also, the critical care provider must recognizing that body habitus can play a role in hindering image acquisition for confirmation, in which case chest Xray still has a role for central line confirmation.