Enhancing Central Venous Cannulation in the Emergency Department
I’m a self described “emergency ultrasound enthusiast.” I spent my early career examining the ways ultrasound could help emergency physicians with their daily clinical questions and trying to demonstrate that point of care ultrasound (POCUS) could have real patient and physician impact in the ED setting. My earliest projects involved making the diagnosis of deep venous thrombosis, elevated intracranial pressure by measuring optic nerve sheath diameter, and identifying testicular and pharyngeal pathology. One of my team’s main focus was performing research to demonstrate that POCUS could change patient outcomes. Ultrasound assisted central venous cannulation (CVC) presented a natural opportunity to examine both physician and patient outcomes.
Decreasing Central Venous Cannulation (CVC) Complicaitons with Point Of Care UltraSound (POCUS)
Our team’s first major focus became comparing the outcomes of POCUS CVC insertions to those where ultrasound was not used. At the Barnes-Jewish ED, most physicians either preferred to use POCUS at the internal jugular site or perform a landmark based sublcavian approach. My team and I set out to compare the two and we found that, overall, POCUS CVC significantly reduced the likelihood of bad outcomes including pneumothorax. We also noted that, as predicted, operator experience would have a great impact on outcomes but POCUS CVC in the hands of less experienced physicians still resulted in decreased complications.
We then leveraged our data set to examine who was most likely to have a complication even with POCUS and concluded that renal failure patients were at greatest risk, likely from their prior dialysis catheter related scarring and their overall increased co-morbidities.
Utilization of Central Venous Cannulation in Emergency Departments
In the early 2000s early goal directed therapy was becoming widely accepted. Critically ill patients were aggressively pursued and part of their resuscitation included CVC to follow physiologic markers and guide therapy. Our group hypothesized that this would bring CVC down from the intensive care unit and into the ED. With a grant for the Agency of Healthcare Research and Quality (AHRQ K08 HS018092) we used the Healthcare Cost and Utilization Project’s (HCUP) California State Inpatient Database (SID) and documented a slow and steady increase in the number of early CVCs placed, presumably in the ED.
This data led us to wonder what the implications of increased CVC utilization in the ED in terms of long term infectious complications.
Risk of Central Line Associated Blood Stream Infection (CLABSI) among catheters inserted in the Emergency Department: ED CLABSI
One of our team’s primary objectives was to document the infectious complications of central venous catheters inserted in the Emergency Department. Over a two-year period we followed the outcomes of 994 catheters inserted in 990 patients by 98 different ED physicians. This required a tremendous collaboration with our infection control and our informatics experts (CADR) but resulted in concluding that central line associated blood stream infection (CLABSI) rates associated with ED insertions were not higher than rates found in other parts of our large academic hospital and, in some instances, were lower. This added to existing evidence that not all ED central lines are “dirty” and require removal but also suggested there was room for improvement. [insert table here].
During this 2-year period our hospital introduced what most of us know as “the bundle,” a package of infection prevention interventions (total body drape, chlorhexadine, sterile insertion kit) designed to prompt the physicians inserting the central line to remember to use maximal precautions to avoid infections. We found a significant decreasing trend of infections after the introduction of the bundle and suggested that infection prevention interventions can work in the ED environment.
ED Checklist Project
Our work to enhance the safety of POCUS assisted CVCs in the ED continues. Our team’s current project is examining the best methods of implementing checklist adoption during insertions. Our preliminary data suggests that there is work to do as we continue to improve the safety of ED procedures.
Incorporating Point Of Care Ultrasound (POCUS) into ACLS algorithms: The Real time Assessment with Sonography Outcomes Network (REASON) Trial
The POCUS emergency medicine community wanted to come together to form a network of teams that answered difficult to study questions. EM sonographers wanted to examine whether intra-arrest factors, such as cardiac activity detected on cardiac POCUS during cardiac arrest could guide management and also prove when to stop resuscitation efforts. The REASON study enrolled over 1,000 patients at 21 different EDs across the nation. Look for our results in upcoming issues of Resuscitation.