Improving Safety and Quality with Best Practices: Focus on Central Venous Access

By Diku Mandavia, MD, FACEP, FRCPC

A recent CDC report found that 1 in 25 hospital patients develop healthcare-associated infections (HAIs). According to the report, about 75,000 of these patients die during their hospital stay.

Device-associated infections and surgical-site infections together accounted for almost half of all HAIs—with infections from central-line placement having reported mortality rates of between 12% and 25%. Using a best practices bundle to place central lines can help prevent—and in the experience of at least one hospital, help eliminate entirely—these costly and harmful mistakes.

The full study identifies central-catheter-associated bloodstream infections as a condition where specific prevention efforts have yielded improvements. The Institute for Healthcare Improvement, for instance, has achieved measurable positive results by designing a “central line bundle” of five key practices regarding central line placements ranging from hygiene checks to expert review of the need for the line. A growing movement is to add a sixth element to the bundle, which is the use of ultrasound to guide the placement of central lines.

Hospitals where physicians added the use of ultrasound to guide the placement of central lines to this bundle of best practices—including leading institutions, such Cedars-Sinai Medical Center in Los Angeles—have seen overwhelming improvements in this area.

While top academic centers have adopted ultrasound-guided line placement as standard practice, many community-based hospitals are not there yet. As a result the human and financial adverse effects continue to increase.

One example should help clarify these stakes. Complications—including but not limited to infections —affect up to 15% of the more than 5,000,000 central venous catheters (CVC) placements performed in the U.S. every year. One of the most serious mechanical complications is iatrogenic pneumothorax, which is the collapse of the patient’s lung following an accidental puncture during CVC placement. This particular mistake can, unfortunately, cost patients their lives and, as such, is part of both the Medicare Hospital Acquired Conditions program as well as a patient safety indicator under the Agency for Healthcare Quality and Research (AHRQ).

AHRQ has also reported that an iatrogenic pneumothorax could cost a hospital up to $45,000, and Medicare has determined it will no longer reimburse hospitals additionally for the cost of this preventable condition. In fact, the financial impact will likely increase, as hospitals with the highest rates of such complications will have their Medicare market basket reduced by 1% across all in-patient payments starting in fiscal year 2015. This rate is set to rise to 2% in future years. (Visit here for these and other references.)

With these policy changes and the publication by CDC of this data, hospitals would do well to follow the example of the White Memorial Medical Center part of the Adventist Health System in Los Angeles. After establishing a central line program that combined the IHI’s bundle approach with ultrasound guidance for all central line placements, between January 2010 and August 2011, White Memorial achieved zero iatrogenic pneumothorax throughout the hospital and zero central line-associated blood stream infections in the ICU. According to Mara Bryant, senior vice president of organizational excellence at the 353-bed hospital. “The numbers really do speak for themselves about the effectiveness of the program. We’ve been able to move from having mechanical complications to having none, and we’ve been able to sustain that over time. We haven’t had a line insertion infection in I can’t remember how long. I’ve learned through this project that you can achieve zero.”

Diku Mandavia is chief medical officer at SonoSite. He is also a clinical associate professor of emergency medicine at the University of Southern California and was an attending staff Pphysician at Cedars-Sinai Medical Center in Los Angeles from 1998-2010. Dr. Mandavia is a founding member and past-chair of the ACEP Ultrasound Section and co-author of the ACEP Ultrasound Guidelines. He received his medical degree from Memorial University in Canada, completed his residency at Los Angeles County+USC Medical Center and is a graduate of the Stanford Executive Program. Mandavia may be contacted at