Ultrasound Guidance for Central Venous Access by Emergency Physicians in Colorado

The western journal of emergency medicine 09/2012; 13(4):320-5. DOI: 10.5811/westjem.2011.11.6821
Source: PubMed


To survey emergency physicians (EP) regarding the frequency of use of ultrasound guidance for placement of central venous catheters (UGCVC) and to assess their perceptions regarding the technique and barriers to its implementation.
A 25-question Web-based survey was e-mailed to all members of the Colorado chapter of the American College of Emergency Physicians with a listed e-mail address. A total of 3 reminders were sent to nonresponders.
Responses were received from 116 out of 330 invitations. Ninety-seven percent (n = 112) of respondents indicated they have an ultrasound machine available in their emergency department, and 78% indicated they use UGCVC. Seventy-seven percent (n = 90) agreed with the statement, "Ultrasound guidance is the preferred method for central venous catheter placement in the emergency department." However, 23% of respondents stated they have received no specific training in UGCVC. Twenty-six percent (n = 28) of respondents stated they felt "uncomfortable" or "very uncomfortable" with UGCVC, and 47% cite lack of training in UGCVC as a barrier to performing the technique.
Although the majority of surveyed EPs feel UGCVC is a valuable technique and do perform it, a significant percentage reported receiving no training in the procedure and also reported being uncomfortable performing it. Nearly half of those surveyed cited lack of training as a barrier to more widespread implementation of UGCVC. This suggests that there continues to be a need for education and training of EPs in UGCVC.

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Available from: Brandon Backlund, Nov 18, 2015
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    • "This evidence has led several large medical organizations and government agencies to recommend the use of ultrasound guidance for CVC.5–9 Despite the evidence and recommendations, surveys have found that the availability of ultrasound in community emergency departments (ED) is less than 50% 10–11 and in those hospitals where access to ultrasound in the ED is higher, almost half of physicians felt they had inadequate training and a quarter of physicians indicated that they felt “uncomfortable” or “very uncomfortable” using ultrasound for CVC.12 "
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    ABSTRACT: Introduction Real-time ultrasound guidance is considered to be the standard of care for central venous access for non-emergent central lines. However, adoption has been slow, in part because of the technical challenges and time required to become proficient. The AxoTrack® system (Soma Access Systems, Greenville, SC) is a novel ultrasound guidance system recently cleared for human use by the United States Food and Drug Administration (FDA). Methods After FDA clearance, the AxoTrack® system was released to three hospitals in the United States. Physicians and nurse practitioners who work in the intensive care unit or emergency department and who place central venous catheters were trained to use the AxoTrack® system. De-identified data about central lines placed in living patients with the AxoTrack® system was prospectively gathered at each of the three hospitals for quality assurance purposes. After institutional review board approval, we consolidated the data for the first five months of use for retrospective review. Results The AxoTrack® system was used by 22 different health care providers in 50 consecutive patients undergoing central venous cannulation (CVC) from September 2012 to February 2013. All patients had successful CVC with the guidance of the AxoTrack® system. All but one patient (98%) had successful cannulation on the first site attempted. There were no reported complications, including pneumothorax, hemothorax, arterial puncture or arterial cannulation. Conclusion The AxoTrack® system was a safe and effective means of CVC that was used by a variety of health care practitioners.
    The western journal of emergency medicine 07/2014; 15(4):536-40. DOI:10.5811/westjem.2014.1.16305
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    ABSTRACT: Objectives The objective was to survey practicing emergency physicians (EPs) across the United States regarding the frequency of using ultrasound (US) guidance in central venous catheter (CVC) placement and, secondarily, to determine factors associated with the use or barriers to the use of US guidance.Methods This was a cross-sectional survey mailed to presumed practicing EPs as part of the American Board of Emergency Medicine (ABEM)'s longitudinal study of EPs. The selection process used stratified, random sampling of cohorts thought to represent four different stages within the development of the specialty of emergency medicine (EM). Multivariable logistic regression was used to identify independent factors associated with both high comfort using US guidance and high-percentage usage of US guidance.ResultsThe survey was mailed to 1,165 subjects, and the response rate was 79%. The median number of years of practice was 20 (interquartile range [IQR] = 7 to 28 years). As their primary practice setting, 64% work in private or community hospitals, 60% received training in US-guided vascular access, and 44% never use US guidance in placing CVCs. Barriers differed in those who never use US and those who sometimes or always used US guidance. In those who never use US, top barriers were insufficient training (67%) and lack of equipment (25%). In those who use US, top barriers were the perceptions that US was too time-consuming (27%) and that the preferred site was not amenable to US (24%). Independent factors associated with high comfort and high-percentage use of US guidance were training in US-guided vascular access (adjusted odds ratio = 5.1 [high comfort]; 95% confidence interval [CI] = 2.6 to 10.1; adjusted odds ratio 11.1 = (high percentage); 95% CI = 5.0 to 24.8) and being a recent residency graduate.Conclusions Among EPs, the translation of evidence to clinical practice regarding the benefits of US guidance for CVC placement is poor and still faces many barriers. Training and education are potentially the best ways to overcome such barriers.ResumenObjetivosEl objetivo fue encuestar a los urgenciólogos de Estados Unidos sobre la frecuencia de uso de ecografía (Eco) para guiar la inserción de un catéter venoso central (CVC); y secundariamente determinar los factores asociados con el uso o con las barreras para usar la guía por Eco.MetodologíaEncuesta transversal vía correo electrónico a los urgenciológos con supuesta actividad asistencial que forman parte del Estudio Longitudinal de Medicina de Urgencias y Emergencias de la American Board. El proceso de selección usó muestras de cohortes estratificadas y aleatorizadas pensadas para representar cuatros etapas diferentes en el desarrollo de la especialidad de urgencias y emergencias. Se utilizó una regresión logística multivariable para identificar los factores independientes asociados tanto con el alto grado de satisfacción como con el alto porcentaje de uso de la guía por Eco.ResultadosLa encuesta fue enviada por correo electrónico a 1.165 sujetos, con un porcentaje de respuesta de un 79%. La mediana de número de años de práctica fue de 20 (rango intercuartílico 7 a 28). Según su escenario de práctica habitual, un 64% trabaja en un hospital privado o de la comunidad, un 60% recibió formación en acceso vascular guiado por Eco y un 44% nunca usa la Eco para guiar la inserción de una CVC. Las barreras difirieron en aquéllos que nunca usan Eco y aquéllos que a veces o siempre usan Eco. En los primeros, las principales barreras fueron la formación insuficiente (67%) y la falta de equipo (25%). En los segundos, las principales barreras fueron las sensaciones que la Eco consumía demasiado tiempo (27%) y que el sitio preferido no era abordable para la Eco (24%). Los factores independientes asociados con un alto grado de satisfacción y un alto porcentaje de uso de la guía por Eco fueron la formación en acceso vascular guiado por Eco (razón de ventajas ajustada 5,1 [alta satisfacción]; intervalo de confianza [IC] 95% = 2,6 a 10,1; razón de ventajas ajustada 11,1 [alto porcentaje]; IC 95% = 5,0 a 24,8) y ser un residente recientemente graduado.ConclusionesEntre los urgenciólogos, la traslación de la evidencia a la práctica clínica sobre los beneficios de la Eco para la guía de la inserción de los CVC es pobre y todavía tiene muchas barreras. La formación y docencia son potencialmente las mejores formas para superar dichas barreras.
    Academic Emergency Medicine 04/2014; 21(4). DOI:10.1111/acem.12350 · 2.01 Impact Factor
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    ABSTRACT: Objectives: The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. Methods: The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. Results: The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters. Conclusions: In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.
    Academic Emergency Medicine 06/2014; 21(6). DOI:10.1111/acem.12386 · 2.01 Impact Factor
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