Implementation of a Central Venous Catheter Placement Initiative with Standardized Training and Credentialing Has Improved Outcomes

General Information

Institution Name: Boston University Chobanian & Avedisian School of Medicine

Author Name and Title: Khu Aten Maaneb de Macedo, MD, Alik Farber, MD, MBA, FACS, Andrea Alonso, MD, MS, Josue Estrella, MD, David McAneny MD, FACS, Jeffrey J. Siracuse, MD, MBA, FACS

Name of Case Study: Implementation of a Central Venous Catheter Placement Initiative with Standardized Training and Credentialing has Improved Outcomes

Figure 1. Rate of CVC Comparisons April 2020–April 2021

Identification of Local Problem

More than five million central venous catheters (CVCs) are placed annually in the United States. Although routine, CVC insertion may be associated with complications such as infection, thrombosis, pneumothorax, and major vascular complications including inadvertent arterial placement, arterial injury, and venous malposition. Inadvertent arterial placement can cause adverse consequences such as bleeding, stroke, and harm to adjacent structures and require major operations or interventions to remove the catheter and repair the injury. The incidence of these major vascular complications at our institution exceeded published benchmarks (Figure 1) and led to the creation and execution of a hospital-wide CVC placement initiative.

Context of the QI Activity

Between April 2020 and April 2021, there were nine major vascular complications following 1,249 CVC placements at our institution. The incidence of these vascular complications exceeded published benchmarks. Details surrounding the complications are included below (Table 1):

Table 1: Major Vascular Complications Following CVC Placement

Complication	Complication Subtype	Counts	Percent (%)
Injury Type	R IJ CVC into R CCA	4	44.4%
	L IJV CVC into L CA	2 (1 CCA, 1 ICA)	22.2%
	R SCV CVC into R SCA/CCA junction	1	11.1%
	R IJV CVC into R SCA to origin of the innominate artery	1	11.1%
	R IJV CVC into L superior intercostal vein	1	11.1%
Supervision	Yes	8*	88.9%
Supervision	No	1**	11.1%
Intervention	Open R IJV ligation or repair with R CCA repair	4	44.4%
	Open L IJV ligation or repair with L CA (ICA or CCA) repair	2	22.2%
	Sternotomy with arterial and venous repairs	2	22.2%
	HD before complication was identified – CVC removed	1	11.1%
Outcome	Major stroke	3 (1 led to death)	33.3%
	Delay in removal	1	11.1%
	No major complications	3	33.3%
	Prolonged hospital course	1	11.1%
	Delay of a scheduled operation	1	11.1%
Services	MICU	1	11.1%
	Renal	1	11.1%
	SICU	2	22.2%
	ED	3	33.3%
	Anesthesia	1	11.1%
	Neuro CC	1	11.1%

Abbreviations: R= right, L= left, CVC=central venous catheter, CCA= common carotid artery, ICA= internal carotid artery, IJV=internal jugular vein, MICU=medical intensive care unit, SICU=surgical intensive care unit, SCV=subclavian vein, SCA=subclavian artery, HD=hemodialysis, ED=emergency department, CC=critical care

Supervision: Most lines were supervised by an attending with two exceptions:* line was supervised by a senior resident (PGY5) ** CVC was placed by a fellow (not supervised by an attending)

These complications are usually preventable with dedicated training and safety measures. A retrospective review of the complications identified a lack of standardized guidelines for CVC placement, technical training, and credentialing of physicians placing CVCs. This prompted the development of a program for targeted improvement across all specialties that place CVCs (surgery subspecialities, interventional radiology, interventional cardiology, nephrology, critical care (neuro and surgical), pulmonary, internal medicine, emergency medicine, and anesthesiology).

What were the interventions?

In May 2021, a multidisciplinary group of expert physicians who place CVCs agreed upon institutional standards for CVC insertion techniques, training, and credentialing for attending surgeons and physicians, advanced practice providers (APPs), and trainees (fellows and residents). The group created a three-tiered training and credentialing framework. The protocol was made mandatory to secure privileges for all providers who place CVCs.

Training requirements vary by experience and tier. Tier 1 includes physicians in specific high-volume procedural specialties or those who place or directly supervise at least 20 CVC placements yearly. Tier 2 includes attending physicians who place or directly supervise more than four CVC placements during a three-year interval. Tier 3 includes all other participants. Training requirements for credentialing were assigned by tier and include video education with an associated 17-question exam (completed by all tiers), hands-on simulation center training (Tiers 2 and 3), and hospital-based proctoring of at least five successful CVC insertions (Tier 3) (Table 2 and 3). A quality committee was convened to oversee CVC-related outcomes.

Table 2: CVC Training and Credentialing Program by Tier

CVC Credentialing Program
Tiers	Physicians and APPs	Trainees	Required Training
1	Credentialed in the following: Vascular Surgery Cardiac Surgery Interventional Radiology Interventional Cardiology Anesthesiology Electrophysiology Place/directly supervise at least 20 CVC insertions annually	Place more than 10 CVCs in two years Supervision is still required	Online Video
2	Place/directly supervise more than four CVC insertions in three years	N/A	Online video Simulation Center
3	Any physicians and APPs not in Tiers 1 or 2	Any trainee not in Tier 1	Online video Simulation Center Hospital-based proctoring (for five successful insertions)

Table 3: Components of the CVC Education and Credentialing Program

Primary Education: Online Video Module	Simulation-Based Instruction Module	Hospital-Based Proctoring
Principles of insertion Indications Proper prepping, draping, and insertion techniques Potential complications and respective treatments Embedded questions	Simulation Center training to reinforce principles of insertion and to allow participants to practice placing CVCs Instructors evaluate participants’ adherence to established standards	Credentialed proctors supervise attending physicians, trainees, and APPs inserting CVCs until they have demonstrated proficiency with five CVCs

Costs and Funding Sources

The Department of Surgery and the Quality and Patient Safety Department at Boston Medical Center provided funding for this effort.

Overall Results and Analysis

Between April 2020 and April 2021, nine major vascular complications (eight inadvertent arterial cannulations and one venous misplacement) occurred among 1,249 patients who had CVCs placed at our institution. The standardized CVC placement program began enrollment in October 2023. As of July 2024, 189 eligible physicians, APPs, and trainees across 13 departments pursued credentialing: 51.3% were Tier 1, 45% were Tier 2, and 3.7% were Tier 3. Many physicians declined to pursue credentialing because they had low CVC volumes and did not intend to continue placing central vein catheters.

Image 1: Chief of Vascular and Endovascular surgery Dr. Jeffrey Siracuse guides resident Dr. Emily Belding during CVC placement session in the Simulation Center.

Follow-up data revealed 86% video completion for Tier 1, 88% video and 99% simulation completion for Tier 2, and 86% video and 57% simulation completion for Tier 3. Proctoring is ongoing for all Tier 3 participants. Only two CVC complications, both inadvertent arterial placements, have occurred in the past two years, since implementation of the initiative.

A quality committee oversees outcomes and adjudicates cases as needed. A recredentialing process was also designed, predicated upon a minimum number of CVCs placed annually and complication rates. This experience affirms that standardization of CVC techniques, training, and credentialing is possible. Furthermore, early returns suggest there may already be improvement in outcomes. Next steps include finishing the credentialing of those who have not yet gone through the process as well as ongoing surveillance.

Limitations

There are some limitations to this report. First, the data were collected from a single institution, perhaps limiting applicability to other settings or a larger cohort of physicians. Second, the absolute number of complications is small, limiting statistical power. Third, participation in credentialing has not yet been universal and baseline data were collected retrospectively, both of which may introduce biases. Finally, improvements in outcomes may reflect other trends or increased institutional awareness, rather than the intervention itself. A longer period of follow-up will be necessary to assess the program’s durability.

Lessons Learned

Standardization of a CVC protocol, including video training, skills simulation, proctoring, and institutional credentialing, seems to be associated with a decrease in the rate of vascular complications and improved patient safety with CVC insertion.