Transcript ICU POINT PREVALENCE AUDIT

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
Audit Trigger
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)
…in extremis
 acutely SOB in PACU
 ABC approach with simultaneous
consideration of diagnoses
• pneumothorax
• PE
• transfusion reaction
• air embolism
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
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• No further air withdrawn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
reduction in upper zone
vascular markings
7mm x 19mm gas shadow
region of the left main
pulmonary artery
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
Venous Air Embolism
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
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
1.
2.
3.
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.
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
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.
Central Line Service
Evaluation
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
Data collection proforma
Audit ID number:
Location:
Bed number:
CVC
Site
R
Lumens in total
1
Lumens in use
1
Reason for CVC
Speciality/Grade of Dr inserting line
Sutures
Fixed connector sutured
Y
Adjustable connector present
Y
Comments
Dressing
Covering insertion site
Y
Clean
Y
L
2
2
IntJug
3
3
Subclavian
4
4
Femoral
5
5
Insertion date
N
N
& sutured
Y
N
N
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
If single bionector attached to lumen then write BIONECTOR across diagram
Leave blank if no clip
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
CVC errors with the potential for VAE
5
Inadequately sutured
28
Three way tap error
19
Incorrect removal position
2
Bungs missing
40
Occlusive dressing absent
64
At least one error
0
Baseline (n=42)
20
40
% of CVCs
60
80
Results: common errors
3 way Tap
CVC lumen
IVI
IVI
Intervention
Intervention
 presentation locally
• raised awareness
• ensure CVC chosen is appropriate
• use of three-way taps?
 hospital standard set
 re-education
• Poster
Prevention of Venous Air Embolism (VAE):
Central Venous Catheter (CVC) Care
1. Service evaluation Oct 09:
% of CVCs with errors potentially
leading to VAE
2. Intervention: Points to remember
CVC insertion site:
CVC sutured to the skin at all times
Insertion site covered by an occlusive dressing
Prevent air from entering CVC:
Prime all syringes & IV giving sets
Use needle-free access devices if possible
Ensure bungs are not cross-threaded
Ensure correct 3-way-tap alignment:
64% of CVCs had an error
64% of CVCs at risk of VAE
✓
✓
✗
✗
✗
Removal:
Follow trust guidelines but remember to:
Lie the patient head down
Apply a sterile occlusive dressing
3. Re-audit planned summer 2010
Re-audit
What next?
What next?
 repeat education / updated posters
Prevention of Venous Air Embolism (VAE):
Central Venous Catheter (CVC) Care
1. Current practice:
% of CVCs with errors potentially
leading to VAE
2. Intervention: Points to remember
CVC insertion site:
CVC sutured to the skin at all times
Insertion site covered by an occlusive dressing
Prevent air from entering CVC:
Prime all syringes & IV giving sets
Use needle-free access devices if possible
Ensure bungs are not cross-threaded
Ensure correct 3-way-tap alignment:
✓
Oct 09: 64% of CVCs at risk of VAE
May 10: 35% of CVCs at risk of VAE
✓
✗
✗
✗
Removal:
Follow trust guidelines but remember to:
Lie the patient head down
Apply a sterile occlusive dressing
3. Re-audit planned Nov 2010
What next?
 repeat education / updated posters
 needle-less valves?
 re-audit 6 months
Summary
Summary
 raised awareness relating to VAE
• prevention
• management
 our hospital’s approach
 consider…
• need for CVC?
• lumens required?
• needle-free valves?
ANY
QUESTIONS?