Mandie Street

Creating and evaluating a data-driven curriculum for central venous catheter placement.

BACKGROUND Central venous catheter placement is a common procedure with a high incidence of error. Other fields requiring high reliability have used Failure Mode and Effects Analysis (FMEA) to prioritize quality and safety improvement efforts. OBJECTIVE To use FMEA in the development of a formal, standardized curriculum for central venous catheter training. METHODS We surveyed interns regarding their prior experience with central venous catheter placement. A multidisciplinary team used FMEA to identify high-priority failure modes and to develop online and hands-on training modules to decrease the frequency, diminish the severity, and improve the early detection of these failure modes. We required new interns to complete the modules and tracked their progress using multiple assessments. RESULTS Survey results showed new interns had little prior experience with central venous catheter placement. Using FMEA, we created a curriculum that focused on planning and execution skills and identified 3 priority topics: (1) retained guidewires, which led to training on handling catheters and guidewires; (2) improved needle access, which prompted the development of an ultrasound training module; and (3) catheter-associated bloodstream infections, which were addressed through training on maximum sterile barriers. Each module included assessments that measured progress toward recognition and avoidance of common failure modes. Since introducing this curriculum, the number of retained guidewires has fallen more than 4-fold. Rates of catheter-associated infections have not yet declined, and it will take time before ultrasound training will have a measurable effect. CONCLUSION The FMEA provided a process for curriculum development. Precise definitions of failure modes for retained guidewires facilitated development of a curriculum that contributed to a dramatic decrease in the frequency of this complication. Although infections and access complications have not yet declined, failure mode identification, curriculum development, and monitored implementation show substantial promise for improving patient safety during placement of central venous catheters.

Optimizing Radiation Use During Fluoroscopic Procedures: A Quality and Safety Improvement Project

PURPOSE The ionizing radiation used during fluoroscopically guided medical interventions carries risk. The teams performing these procedures seek to minimize those risks while preserving each procedures benefits. This report describes a data-driven optimization strategy. METHODS Manual and automated data capture systems were used to collect a series of different metrics, including fluoroscopy time, kerma area product, and reference point air kerma, from both adult and pediatric interventional radiologic procedures. Tools from statistical process control were used to identify opportunities for improvement and assess which changes led to improvement. RESULTS Initial efforts focused on creating a system capable of reliably capturing fluoroscopy time from all interventional radiologic procedures. Ongoing data analysis and feedback to frontline teams led to the development of a manual workflow that reliably captured fluoroscopy time. Data capture was later supplemented by automatic capture of electronic records. This process exploited the standardized format (DICOM Structured Reporting) that newer fluoroscopy units use to record the radiation metrics. Data analysis found marked differences between the imaging protocols used for adults and children. Revision of the adult protocols led to a stable twofold reduction in average exposure per adult procedure. Analysis of balancing measures found no impact on workflow. CONCLUSIONS A systematic approach to improving radiation use during procedures led to a substantial and sustained reduction in risk with no reduction in benefits. Data were readily captured by both manual and automated processes. Concepts from cognitive psychology and information theory provided a theoretical basis for both data analysis and improvement opportunities.

Audio and Video Recording System for Routine Documentation of Fluoroscopic Procedures

Because aviation and other reliable systems routinely record and analyze performance, the authors investigated the feasibility and utility of installing a system capable of recording image-guided procedures. An audio/video recording system adapted from those used in simulation laboratories was installed in a new pediatric interventional radiology suite. In this report, the authors describe the recording system as well as how it can be used to study radiation use during individual procedures. These results illustrate how routinely recording more than 300 procedures during the past 14 months and the detailed analysis of selected recordings can provide insights that lead to continual improvements in performance.

Optimizing radiation use during fluoroscopic procedures: proceedings from a multidisciplinary consensus panel.

James R. Duncan, MD, PhD, Stephen Balter, PhD, Gary J. Becker, MD, Jeffrey Brady, MD, MPH, James A. Brink, MD, Dorothy Bulas, MD, Mythreyi B. Chatfield, PhD, Simon Choi, PhD, MPH, Bairbre L. Connolly, MB, Robert G. Dixon, MD, Joel E. Gray, PhD, Stephen T. Kee, MD, Donald L. Miller, MD, Donald W. Robinson, LTC, MD, Mark J. Sands, MD, David A. Schauer, DSc, Joseph R. Steele, MD, Mandie Street, RT, Raymond H. Thornton, MD, and Robert A. Wise, MD