Kimberly Burkiewicz, ACNP, CPNP, DNP, RN
Acute Care APRN
Children's Hospital of Illinois
Peoria, Illinois
Disclosure information not submitted.
Sandeep Tripathi, MD, MS
Associate Professor of Pediatrics
University of Illinois College of Medicine at Peoria
Peoria, Illinois
Disclosure information not submitted.
Title: Targeting Highest risk: Implementation of CVC insertion bundle to influence DVT rates in the PICU
Introduction: Catheter Associated Deep Vein Thrombosis (CADVT) incidence is estimated to occur in 141 per 10,000 children with central venous catheters. Vein size < twice the outer diameter of the catheter, and >2 attempts at insertion have been shown to be associated with development of DVT; however, no prior study has shown a reduction in DVT by monitoring and mitigating risks introduced by these factors by providers during insertion.
Methods: A Quality Improvement (Q.I) project (within the auspices of Solutions for Patient Safety, a national collaborative) focusing on monitoring of DVT bundle compliance (use of ultrasound, documentation of vein size > twice the outer diameter of catheter and documentation of number of attempts) was implemented in the pediatric ICU from 07/2019 to 03/2021. All central venous catheter insertion notes were manually reviewed to assess compliance. Individual provider level and group level compliance was calculated and reported quarterly. Process stability was tracked using statistical process control (X and mR chart).
Results: Over 21 months, total of 453 CVC insertions notes were audited with an overall compliance with all bundle elements of 54.2% (228/420 eligible catheter insertions). The compliance remained within the Upper and lower control limits during the project. Nurse driven Percutaneously Inserted Central venous catheter (PICC) team had the highest compliance (84%, 73/87) of all the groups inserting central venous catheters while the compliance was lowest for surgical teams (0%, 0/75). Of the individual elements, Ultrasound use compliance was 79% (333/422), vein size compliance was 55% (234/424) and compliance with number of attempts was 84.5% (257/304). Out of 25 providers who had inserted ≥ 3 catheters, only one had 100% compliance (26/26) for the duration of project, while 64% (16/25) had ≥ 80% compliances. Median number of DVT/month in the PICU decreased from a median of 4 (IQR 1, 4) in 2018, to 2 (IQR 1, 4) in 2019 and 2 (IQR 1, 3) in 2020.
Conclusions: Cognizance of the vein size and number of attempts at insertion of the central line, along with meticulous monitoring of compliance, can decrease the incidence of deep vein thrombosis in pediatric ICU.