Nurse-led central venous catheter insertion: review of 760 procedures performed across three hospitals reveals a low rate of complications
- Correspondence to Linda J Kelly
Department of Health, Nursing and Midwifery, University of the West of Scotland, Hamilton Campus, Almada Street, Hamilton ML3 0JB, UK;
Implications for practice and research
■ Nurse-led central venous catheter (CVC) placement is a safe alternative to medical led CVC placement.
■ Nurse-led CVC services can potentially improve organisational efficiency and patient safety.
■ Training, education and adequate procedural volumes are all necessary to ensure optimal outcomes.
■ Larger international studies are required to identify the impact of nurse-led CVC services.
For many years, CVC insertion was the doctor's domain. However, CVC insertion by nurses began to evolve in the late 1990s. This role has continued to develop with the number of nurse-led vascular access services steadily increasing. The measurement of the effectiveness of nurse-led clinics should be an integral part of the service and should encompass the areas of audit, evaluation and research. To date, research in this area is sparse.
Research indicates that there is an inverse relationship between a healthcare professional's experience and their rate of complications as demonstrated in early studies.1,–,3 To review the procedural characteristics and outcomes of three nurse-led CVC insertion services in New South Wales (NSW), Alexandrou et al used data obtained from a previous project which had been undertaken with the aim of reducing the central line associated bacteraemia (CLAB) incidence in NSW.
CLAB accounts for approximately 60% of nosocomial acquired infections in intensive care patients. The current study was based on the premise that CLAB is caused by contamination at the time of insertion.
Adult and paediatric patients in the intensive care units in NSW participated in the project between March 2007 and June 2009. Data received from the project were loaded into the STATA Version 7.0 package. Descriptive statistics were presented as frequencies and proportions. Categories were tabulated and analysed using the fisher's exact test and included: catheter type, catheter coating and insertion outcomes. CIs were used to assess range with some variables and to assess differences across the three hospitals sites. Standardised checklists were used to ensure that each service complied with a full aseptic technique including the use of an antimicrobial solution (between 1% and 2% chlorhexidine in 70% alcohol), use of full sterile draping, sterile gloves and gown with cap and surgical mask.
Throughout the project, 760 vascular access devices were inserted by the three nurse-led CVC insertion services. Minimal insertion complications (p<0.001) were noted. Hospital A recorded one pneumothorax (1%) and one catheter malposition (1%). Hospital C recorded a small proportion of catheter malpositions (N=7 or 4%) and one arterial puncture (1%). One CLAB was reported during the study which was attributed to Hospital C (1% or 6.1 per 1000 catheters for hospital C). Hospital C also recorded one failed insertion. This study found a great variety in the insertions across the hospital sites. These variations included: types of catheters inserted (midlines, peripherally inserted central catheters, intravenous cannulas, high flow/dialysis catheters), use of ultrasound guidance, insertion site and catheter coating preference.
This current study demonstrates that it is the experience and competence of the practitioner inserting the device that leads to optimum patient outcomes rather than the professional group performing the procedure. The study also demonstrates that complication rates of the nurse-led services are minimal with only one CLAB noted across the three nurse-led groups (1% or 1.3 per 1000 catheters). This was attributed to the strict adherence to infection control and aseptic technique during catheter insertion which correlates with other studies in this area. However, the data used for this study were obtained from a quality project which utilised convenient sampling and consecutive catheter placement with no randomisation. Therefore, there is the potential for bias and measurement errors. In addition, there were many variations in the insertion techniques across the sites which were not fully explored.
Finally, there was no explanation for Hospital C recording the highest number of complications. Despite the lack of definitive results, this study adds additional support to previous studies demonstrating that nurse-led CVC services can lead to improved patient outcomes. The study has several implications for future research regarding procedural characteristics and outcomes.